NAPLEX 2021 FINAL OVERVIEW

DOC for Carbapenem-resistant gram-negative rods (CRE)

- Ceftazidime/avibactam - Colistimethate, polymyxin B

Drug TX T2D No ASCVD - need to minimize hypoglycemia

- DPP-4i - GLP-1 RA - SGLT-2i - TZD

DOC VRE (Vancomycin resistant Enterococci faecium)

- Daptomycin - Linezolid - Cystitis only: - nitrofurantoin, fosfomycin, doxycycline

Diabetes and Cholesterol Control

- Diabetes + ASCVD or 50 - 75 with multiple ASCVD RF: - High intensity statin - Diabetes W/O ASCVD and 40 - 75 - Moderate intensity statin - Diabetes W/O ASCVD and < 40 - no statin - with RF: moderate intensity statin Can add ezetimibe to max tolerated dose of statin if ASCVD 10-yr > 20% If LDL controlled but TG are 135 - 499 add icosapent ethyl (Vascepa)

DOC for Methicillin-sensitive Staphylococcus aureus (MSSA)

- Dicloxacillin, nafcillin, oxacillin - Cefazolin, cephalexin (and other 1st and 2nd gen cephalosporins) - Amoxicillin/clavulanate, ampicillin/sulbactam

Emollient (Stool Softeners)

- Docusate sodium: Colace (+ senna: Senna S)

Drug TX T2D No ASCVD - need weight loss

- GLP-1 RA - semaglutide, liraglutide, dulaglutide or - SGLT-2i

Cefotaxime

- 3rd gen group 1 cephalosporin - DF: IV/IM - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash. - Common uses: CAP, meningitis, SBP, pyelonephritis

Induction of remission options for Ulcerative Colitis

- 5-ASA (oral and/or rectal) +/- steroids - Anti-TNF (infliximab, adalimumab, certolizumab) +/-thiopurine - Ustekinumab (Stelara) (interleukin receptor antagonists) - Tofacitinib (Xelijanz) - IV cyclosporine

Ampicillin

- Aminopenicillin (start with A) - DF: injection, cap, suspension - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash - RARELY USED, POOR BIOAVAILBILITY - IV must be diluted in NS ONLY

KD Antibiotics that do NOT require renal adjustment

- Antistaphylococcal penicillins (dicloxacillin, nafcillin) - Ceftriaxone - Clindamycin - Doxycycline - Macrolides (azithromycin and erythromycin only) - Metronidazole - Moxifloxacin - Linezolid

Hypoglycemia

- BG < 70 - Symptoms - dizziness, diaphoresis (sweating), hunger, confusion, ataxia, tremors, palpations, tachycardia - severe: seizures, coma and death

Sulfonylureas

- BN: - Glipizide: Glucotrol - Glimepiride: Amaryl - Glyburide: Glynase - MOA: increases insulin secretion, decreases A1C 0.8% - ADE: weight gain, hypoglycemia - CI: sulfa allergy - Beers criteria: do not use in elderly due to hypoglycemia

Pioglitazone

- BN: Actos - MOA: thiazolidinedione increases muscle cell-sensitivity to insulin to increase BG entry - decreases A1C 1% - ADE: edema, weight gain, bone fractures, URTI's - BBW: do not use with NYHA class III/IV HF - Warning: Can stimulate ovulation, can cause bladder CA (avoid if hx), hepatic failure

Cefazolin

- BN: Ancef - 1st gen cephalosporin - DF: IV/IM - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash. - Common use: surgical prophylaxis

Amoxicillin/Clavulanate

- BN: Augmentin - Aminopenicillin (start with A) - DF: tab, chewable, suspension - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. -CI: hx of cholestatic jaundice or hepatic dysfunction associated with previous use - ADE: seizures (with accumulation), GI upset, diarrhea, rash - CrCL > 30 do not use XR

Rosiglitazone

- BN: Avandia - MOA: thiazolidinedione increases muscle cell-sensitivity to insulin to increase BG entry - decreases A1C 1% - ADE: edema, weight gain, bone fractures, URTI's - BBW: do not use with NYHA class III/IV HF - Warning: Can stimulate ovulation, hepatic failure

Moxifloxacin

- BN: Avelox - Fluoroquinolone antibiotic - MOA: inhibit bacterial DNA topoisomerase IV and DNA gyrase (topoisomerase II). - Concentration dependent antibacterial activity (high Cmax wanted) - BBW: - tendon inflammation or rupture - peripheral neuropathy - CNS effect, seizures - avoid in pts with MG - Warning QT prolongation - ADE: N/D, HA, dizziness, serious skin rxns, photosensitivity - Only fluoroquinolone not used for UTIs

Aztreonam

- BN: Azactam - Monobactam with similar MOA to beta-lactams - Primarily used when there is a beta-lactam ALLERGY - cover many gram - (including pseudomonas), NO gram + or anaerobic activity - DF: injection - ADE: seizures (with accumulation), GI upset, diarrhea, rash.

Azathioprine

- BN: Azasan, Imuran - thiopurine for UC and CD - BBW: chronic immunosuppression increases risk of malignancy in patients with IBD; mutagenic potential; risk for hematological toxicities. - Warning: hematological toxicities; patients with a genetic deficiency of thiopurine methyltransferase (TPMT) are at risk for myelosuppression. - ADE: NVD, rash, increased LFTs

sulfamethoxazole/trimethoprim

- BN: Bactrim - MOA: SMX inhibits dihydrofolic acid formation which interferes with bacterial folic acid synthesis. TMP: inhibits dihydrofolic acid reduction to tetrahydrofolate, resulting in inhibition of the folic acid pathway. - CI: sulfa allergy, pregnancy, breastfeeding, renal or hepatic disease, infants <2 months - Warnings: skin rxns and thrombotic thrombocytopenic purpura (TTP) - ADE: photosensitivity, increased K, hemolytic anemia, crystalluria, N/V/D - DDI: can increase INR, try not to use with warfarin - Common uses: MRSA skin infections, UTIs, PCP

Mupirocin

- BN: Bactroban - Use: topical ointment used to eliminate MRSA colonization in the nares

Clarithromycin

- BN: Biaxin - Macrolide antibiotic - Concentration dependent (high Cmax) - MOA: bind to the 50S ribosomal subunit inhibiting RNA-dependent protein synthesis - CI: hx of cholestatic jaundice/hepatic issues with prior use. - use with lovastatin, simvastatin - Major 3A4 substrate and inhibitor - Also used on tx for H. pylori

Penicillin G Benzathine

- BN: Bicillin L-A - DF: IM - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash - DOC for SYPHILIS

Exenatide

- BN: Byetta, Bydureon - MOA: GLP-1 RA incretin mimetic, which decrease glucagon and slows gastric emptying. A1C decrease 1% - BIG BENEFIT: ASCVD -ADE: NV, decreased appetite, weight loss, dyspepsia - do not use with DDP-4i's because same MOA - BBW: do not use if personal/family hx of medullary thyroid CA or hx of multiple endocrine neoplasia (MEN2). Warning: Pancreatitis

Cefotetan

- BN: Cefotan - 2nd gen cephalosporin - DF: IV/IM - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash. - Common uses: AOM, CAP, sinus infection - Has a side chain that can increase risk of bleeding and cause disulfiram-like reaction with alcohol

Cefuroxime

- BN: Ceftin - 2nd gen cephalosporin - DF: PO, IV/IM - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash. - Common uses: AOM, CAP, sinus infection

Ciprofloxacin

- BN: Cipro - Fluoroquinolone antibiotic - MOA: inhibit bacterial DNA topoisomerase IV and DNA gyrase (topoisomerase II). - Concentration dependent antibacterial activity (high Cmax wanted) - BBW: - tendon inflammation or rupture - peripheral neuropathy - CNS effect, seizures - avoid in pts with MG - Warning QT prolongation - ADE: N/D, HA, dizziness, serious skin rxns, photosensitivity - CI: use with tizanidine (zanaflex)

Clindamycin

- BN: Cleocin - MOA: lincosamide 50S - BBW: C. diff colitis - ADE: N/V/D - for anaerobes and gram +

Daptomycin

- BN: Cubicin - cyclic lipopeptide - for gram + - concentration dependent antibacterial activity - Uses: SSTI's, MRSA blood infections, right sided endocarditis - deactivated by pulm surfactant (do not use for lungs) - Warning: myopathy and rhabdomyolysis - ADE: increased CPK, ab pain, chest pain, edema, HTN

Fidaxomicin

- BN: Dificid - MOA: inhibits RNA polymerase - Use: C.diff ONLY - ADE: N/V, ab pain, GI bleeding, anemia

Erythromycin

- BN: E.E.S, Ery-tab, Erythrocin - Macrolide antibiotic - Concentration dependent (high Cmax) - MOA: bind to the 50S ribosomal subunit inhibiting RNA-dependent protein synthesis - CI: hx of cholestatic jaundice/hepatic issues with prior use. - use with lovastatin, simvastatin - Major 3A4 substrate and inhibitor

Metronidazole

- BN: Flagyl - MOA: cause loss of helical DNA structure and strand breakage - Use: anaerobes and protozoal infections, bacterial vaginosis, trichomoniasis, C. diff, and in combo for intra-ab infections - CI: pregnancy, alcohol (disulfiram rxn) - ADE: metallic taste, HA, N, furry tongue

Ceftazidime

- BN: Fortaz - 3rd gen group 2 cephalosporin - DF: IV/IM - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash. - Active against Pseudomonas, lacks gram positive coverage

Metformin

- BN: Glucophage, Fortamet - MOA: decreases hepatic glucose output, increases insulin sensitivity and decreases intestinal glucose absorption. - A1C decrease 1 - 1.5% - take with food to minimize D/N and farts - BBW: lactic acidosis - Warnings: - do not start if eGFR < 45 - can cause vitamin B12 deficiency - stop prior to iodinated contrast - CI: eGFR < 30

Ertapenem

- BN: Invanz - Carbapenem antibiotic (beta-lactam) - DF: IV/IM - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - Do not use in pt with a penicillin allergy - ADE: CNS (confusion and seizures), diarrhea, rash, bone marrow suppression - No coverage of pseudomonas, acinetobacter or enterococcus - Stable in NS only

Canagliflozin

- BN: Invokana - MOA: SGLT-2i increase BG renal excretion (decrease A1C 0.7 - 1%) - BIG BENEFIT: HF and CKD decrease dose with renal impairment - ADE: UTI's, genital fungal infections - BBW: amputation risk - Warning: bone fracture risk

Sitagliptin

- BN: Januvia - MOA: DPP-4i increases incretin-> less glucagon. Lowers A1C 1% - Do not use with GLP-1 RA because similar MOA - decrease for renal impairment (not linagliptin) - Warning: pancreatitis, severe arthralgia, acute renal failure

Empagliflozin

- BN: Jardiance - MOA: SGLT-2i increase BG renal excretion (decrease A1C 0.7 - 1%) - BIG BENEFIT: HF and CKD decrease dose with renal impairment - ADE: UTI's, genital fungal infections

Cephalexin

- BN: Keflex - 1st gen cephalosporin - DF: PO - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash. - common uses skin infection (MSSA) and strep throat

Levofloxacin

- BN: Levaquin - Fluoroquinolone antibiotic - MOA: inhibit bacterial DNA topoisomerase IV and DNA gyrase (topoisomerase II). - Concentration dependent antibacterial activity (high Cmax wanted) - BBW: - tendon inflammation or rupture - peripheral neuropathy - CNS effect, seizures - avoid in pts with MG - Warning QT prolongation - ADE: N/D, HA, dizziness, serious skin rxns, photosensitivity

Nitrofurantoin

- BN: Macrodantin, Macrobid - MOA: bacterial cell wall inhibitor - Use: DOC uncomplicated UTIs only (cystitis) - CI: renal impairment < 60 - Warning: hemolytic anemia (caution in pts with G6PD deficiency - ADE: GI upset (take with food), brown urine discoloration (harmless)

Cefepime

- BN: Maxipime - 4th gen cephalosporin (only one) - DF: IV/IM - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash. - Active against Pseudomonas, similar gram positive coverage to ceftriaxone

Meropenem

- BN: Merrem - Carbapenem antibiotic (beta-lactam) - DF: IV - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - Do not use in pt with a penicillin allergy - ADE: CNS (confusion and seizures), diarrhea, rash, bone marrow suppression

Minocycline

- BN: Minocin, Solodyn - MOA: inhibit bacterial protein synthesis by binding 30S ribosome - Do not use in pregnancy, breastfeeding or children <8 (permanent tooth discoloration) - ADE: N/V/D, rash, photosensitivity - Common uses: MRSA skin infections, acne

Amoxicillin

- BN: Moxatag - Aminopenicillin (start with A) - DF: tab, cap, chewable, suspension - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash - CrCL > 30 do not use XR

Cefdinir

- BN: Omnicef - 3rd gen group 1 cephalosporin - DF: PO - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash.

Semaglutide

- BN: Ozempic - MOA: GLP-1 RA incretin mimetic, which decrease glucagon and slows gastric emptying. A1C decrease 1% - BIG BENEFIT: ASCVD -ADE: NV, decreased appetite, weight loss, dyspepsia - do not use with DDP-4i's because same MOA - BBW: do not use if personal/family hx of medullary thyroid CA or hx of multiple endocrine neoplasia (MEN2). Warning: Pancreatitis

Penicillin V Potassium

- BN: Pen VK - DF: tab, suspension - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash

Ceftriaxone

- BN: Rocephin - 3rd gen group 1 cephalosporin - DF: IV/IM - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash. - Common uses: CAP, meningitis, SBP, pyelonephritis - NO RENAL DOSE ADJUSTMENT, do not use in neonates <28 days old because it causes biliary sludging

Quinupristin/Dalfopristin

- BN: Synercid - MOA: 50S - Covers most gram + but not E. faecalis - Uses: SSTI's - not well tolerated - ADE: arthralgias/myalgias (47%), infusion rxns, hyperbilirubinemia

Ceftaroline

- BN: Teflaro - 5th gen cephalosporin (only one) - DF: IV - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash. - Only beta-lactam with MRSA coverage

Dulaglutide

- BN: Trulicity - MOA: GLP-1 RA incretin mimetic, which decrease glucagon and slows gastric emptying. A1C decrease 1% - BIG BENEFIT: ASCVD -ADE: NV, decreased appetite, weight loss, dyspepsia - do not use with DDP-4i's because same MOA - BBW: do not use if personal/family hx of medullary thyroid CA or hx of multiple endocrine neoplasia (MEN2). Warning: Pancreatitis

Tigecycline

- BN: Tygacil - MOA: 30S - BBW: increase risk of death - Warnings: hepatoxicity, pancreatitis, photosensitivity, tooth discoloration in children < 8 - do not use for bloodstream infections - red/orange colored solution

Ampicillin/Sulbactam

- BN: Unasyn - Aminopenicillin (start with A) - DF: injection - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. -CI: hx of cholestatic jaundice or hepatic dysfunction associated with previous use - ADE: seizures (with accumulation), GI upset, diarrhea, rash - Dilute in NS ONLY

Vancomycin

- BN: Vancocin - MOA: glycopeptide that inhibits bacterial cell wall synthesis by binding to the D-alanyl-D-alanine cell wall precursor and blocking peptidoglycan polymerization - For gram positive only - Warnings: ototoxicity and nephrotoxicity - infusion rnx/red mans syndrome - ADE: ab pain, phlebitis, myelosuppression - Monitor: renal function, AUC/MIC ratio - 1st line for MRSA - PO can be used for C. diff only

Doxycycline

- BN: Vibramycin - MOA: inhibit bacterial protein synthesis by binding 30S ribosome - Do not use in pregnancy, breastfeeding or children <8 (permanent tooth discoloration) - No adjustment for renal impairment - ADE: N/V/D, rash, photosensitivity - Common uses: MRSA skin infections, acne, 1st line for lyme disease, rocky mountain spotted fever, CAP, COPD exacerbation, sinusitis, combo therapy for gonorrhea

Liraglutide

- BN: Victoza - MOA: GLP-1 RA incretin mimetic, which decrease glucagon and slows gastric emptying. A1C decrease 1% - BIG BENEFIT: ASCVD -ADE: NV, decreased appetite, weight loss, dyspepsia - do not use with DDP-4i's because same MOA - BBW: do not use if personal/family hx of medullary thyroid CA or hx of multiple endocrine neoplasia (MEN2). Warning: Pancreatitis

Azithromycin

- BN: Z-Pak, Zithromax - Macrolide antibiotic - Concentration dependent (high Cmax) - MOA: bind to the 50S ribosomal subunit inhibiting RNA-dependent protein synthesis - Dosing: 500 mg day 1 then 250 mg days 2 - 5 - CI: hx of cholestatic jaundice/hepatic issues with prior use. - Warning: QT prolongation, hepatoxicity - ADE: GI upset

Piperacillin/tazobactam

- BN: Zoysn - Extended-Spectrum penicillin - DF: Injection - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - ADE: seizures (with accumulation), GI upset, diarrhea, rash

Linezolid

- BN: Zyvox - MOA: bind 50S subunit - IV:PO 1:1 - similar coverage as vancomycin, but cover VRE - CI: do not use within 2 weeks of MAOI - Warnings: duration-related myelosuppression, peripheral and optic neuropathy, serotonin syndrome, hypoglycemia - ADE: decreases platelets, decreased HGB, HA, N/D

Cephalosporin Overview

- Beta-lactam antibiotic - Not active against Enterococcus spp. or atypicals - 5 groups - DDI: drugs that decrease stomach acid can decrease the bioavailability and should be spread out by 2 hours from short acting antacids and PPIs and H2RA should be avoided - do not choose a cephalosporin on the exam if the patient has a penicillin allergy

Carbapenems Overview

- Beta-lactam antibiotic with very broad spectrum that are generally reserved for MDR Gram-negative infections - Active against gram + and - (including ESBL-producing bacteria - No coverage for atypical pathogens, MRSA, VRE, C. diff or Stenotrophomonas - can decrease conc of valproic acid increasing seizure risk. - DO NOT use if a pt has a penicillin allergy

Insulin - CI - Warnings - ADE

- CI: Acute hypoglycemia. Afrezza and lung disease, do not use in active smokers - Warnings: hypoglycemia, hypokalemia, - ADE: weight gain, lipoatrophy

High Risk Incompatibilities

- Calcium and Ceftriaxone - Calcium and Phosphate - Lactated ringers contain Calcium - Amphotericin and Sodium bicarbonate are incompatible with most IV drugs - Heparin has a lot of incompatibles

DOC Extended spectrum beta-lactamase producing gram negative rods (ESBL, GNR) - E. coli, K. pneumoniae

- Carbapenems - Ceftolozane/Tazobactam - Ceftazidime/Avibactam

DOC for Acinetobacter baumannii

- Carbapenems (except ertapenem)

Insulin stability

- Most stable at room temp for 28 days - Pens sometimes have shorter stability

DOC VRE (Vancomycin resistant Enterococci faecalis)

- Pen G or ampicillin - Linezolid - Daptomycin - Cystitis only: - nitrofurantoin, fosfomycin, doxycycline

Inpatient Parenteral penicillins 1st liners

- Penicillin G Benzathine (Bicillin L-A): DOC syphilis, not for IV because it can cause death - Nafcillin: covers MSSA only (no MRSA), no renal dose adjustment needed - Piperacillin/tazobactam (zoysn): only penicillin active against pseudomonas. Extended infusion can be used for time dependent killing

Outpatient oral penicillins 1st liners

- Penicillin VK: 1st line for strep throat and mild nonpurulent skin infections - Amoxicillin: 1st line for acute otitis media, DOC for infective endocarditis prophylaxis before dental procedures, used in H. pylori infections - Amoxicillin/Clavulanate (Augmentin): 1st line AOC, and for sinus infections - Dicloxacillin and Oxacillin: covers MSSA only (no MRSA), no renal dose adjustment needed

Most likely drug classes for allergies

- Penicillin's - Sulfonamides

Opioid DDI

- Use caution with other CNS depressants (alcohol, hypnotics, benzos, and muscle relaxants. - Hydrocodone, fentanyl, methadone, and oxycodone are 3A4 substrates, avoid with inhibitors.

DOC for nosocomial MRSA

- Vancomycin - Linezolid - Daptomycin (not in lungs)

Anticoagulant antidotes - Warfarin - heparin - dabigatran - apixaban

- Warfarin: phytonadione (vitamin K) - Prothrombin complex concentrate (Kcenta) for warfarin and factor Xa inhibitors - heparin: protamine - dabigatran: praxbind - apixaban: andexanet alfa (andexxa)

Quinolones DDI

- antacids and other polyvalent cations (mg, al, ca, iron, zinc) multivitamins, sucralfate, and bile acid resins can chelate and inhibit absorption. - increase effects of sulfonylureas and insulin - caution with CVD, decrease K and Mg and other QT prolonging drugs - can increase levels of caffeine and theophylline

KD that can cause diarrhea

- antacids containing magnesium - antibiotics - antidiabetics (metformin, GLP-1 agonists) - Antineoplastics (irinotecan, capecitabine, fluorouracil, methotrexate, TKI's) - colchicine - drugs used for constipation - misoprostol - mycophenolate - prokinetic drugs (metoclopramide, cisapride) - protease inhibitors ("-navir") - quinidine - roflumilast

Heavy metals antidote - arsenic - copper - gold - lead - mercury

- arsenic: dimercaprol - copper: penicillamine - gold: dimercaprol - lead: succimer (chemet) - mercury: dimercaprol

DOC for Atypical organisms

- azithromycin, clarithromycin - doxycycline - quinolones

Drugs that increase BG

- beta blockers (can increase and decrease BG) - thiazide and loop diuretics - tacrolimus - cyclosporine - protease inhibitors - quinolones - antipsychotics (olanzapine, quetiapine) - statins - steroids (systemic) - cough syrups - niacin

DOC HNPEK

- beta-lactam/beta-lactamase inhibitor

Vesicant

- drug that will cause severe tissue damage if the catheter tip falls out of the vein, allowing the drug to seep into surrounding tissue. - preferred to use central lines - drugs: - vasopressors (dopamine, norepinephrine) - anthracyclines (doxorubicin) - vinca alkaloids (vincristine, vinblastine) - digoxin - foscarnet - nafcillin - mannitol - mitomycin - promethazine (can cause severe tissue injury so DO NOT give intra-arterial) and do not give to children under 2

Epinephrine Auto-Injector Administration

- inject into the middle of the outer thigh only at a 90 degree angle - hold the needle firmly in place while counting to 3 - remove needle and massage area for 10 seconds - a second dose in the opposite leg may be given if needed prior to arrival of help - all products can be injected through clothing - check the device periodically to make sure its not expired

Drugs that decrease BG

- linezolid - lorcaserin - beta blockers (can increase and decrease BG) - quinolones - tramadol

T2D drugs that cause weight loss and no hypoglycemia

- metformin - GLP-1 RA: "-glutide" - SGL2i: "-flozin"

Which OTC constipation drug? - most adults? - iron-induced or hard stool? - opioid induced? - pregnancy? - fast relief needed?

- most adults: fiber (bulk-forming) - iron-induced or hard stool: docusate (stool softener) - opioid induced? senna or bisacodyl (stimulant) - pregnancy? fiber (bulk) - fast relief needed? - Adults: bisacodyl or glycerin suppository - children: glycerin suppository

Skewed Distribution

- not symmetrical - 68% of values do not fall within 1 SD of mean usually occurs when sample size is small and/or there are outliers Skew refers to the direction of the tail. Data is skewed towards the outliers. When there are more low values in data and outliers have higher values the data is skewed right (positive skew)

Combination Oral Contraceptives (COC) Uses

- pregnancy prevention - dysmenorrhea - PMS - Acne - anemia - peri-menopausal symptoms - menstrual associated migraine prophylaxis - polycystic ovary syndrome (PCOS)

The Five Rights

- right route - right patient - right medication - right dosage - right time helps prevent medication errors

T2D treatment and A1C above goal

- start with metformin if eGFR > 30 - if A1C >1.5% above goal combo therapy - Insulin can be added if A1C > 10% or BG > 300

Induction of Remission for Crohn's Disease

- steroids (+/- thiopurine or methotrexate) - Anti-TNF (infliximab, adalimumab, certolizumab) +/-thiopurine - Ustekinumab (Stelara) (interleukin receptor antagonists)

Starting Insulin in T1D

- typical daily dose is 0.5 units/kg/day. Use 50% as basal and 50% as prandial - Divide the bolus dose into 3 doses

DOC for C. diff

- vancomycin (oral) - fidaxomicin

Topical Adjuvants for Pain

- Lidocaine (Lidoderm) - Capsaicin (Zostrix) - Methyl salicylate (BenGay, Icy Hot, SalonPas

Acute Gout Attack Therapy

A single drug is recommended from colchicine, an NSAID or steroid. For more severe disease you can use colchicine and an NSAID or steroid Colchicine: Colcrys NSAIDS: - Indomethacin (Indocin) - Naproxen (Aleve) - Celecoxib (Celebrex) Steroids - Prednisone/Prednisolone - Methylprednisolone - Triamcinolone

autonomic nervous system

A subdivision of the peripheral nervous system. Controls involuntary activity of visceral muscles and internal organs and glands. Acetylcholine: parasympathetic, increased SLUDD NE and EPI: sympathetic, fight or flight

Drug allergies

A type B ADR and categorized into 4 types Type 1 rxns: immediate, within 15-30 minutes - urticaria, bronchospasm, angioedema, anaphylaxis Type 2 rxns: minutes to hours after drug exposure - hemolytic anemia, thrombocytopenia Type 3 rxns: immune-complex rxns; occur 3-10 hrs after drug exposure - drug induced lupus erythematosus Type 4 rxns: delayed hypersensitivity rxns; can occur anywhere from 48 to several weeks later. - PPD skin test for TB

Naranjo Scale

A validated causality assessment scale that can help pharmacists determine the likelihood that a drug caused an ADR >/= 9 definite ADR 5-8 probable ADR 1-4 possible 0 doubtful

BMP: Serum Creatinine

0.6 - 1.3 increases: many drugs that impair renal function (aminoglycosides, amphotericin B, cisplatin, colistimethate, cyclosporine, loop diuretics, polymyxins, NSAIDs, radioactive contrast dye, tacrolimus, vancomycin decreases: low muscle mass, amputation, hemodilution

Diabetic ketoacidosis and Hyperosmolar Hyperglycemia State Treatment

1. aggressive fluids NS and when BG hits 200 change to D5W1/2NS 2. regular insulin infusion 3. prevent hypokalemia, monitor K and keep between 4 - 5 4. treat acidosis, give bicarb if necessary

BMP Magnesium

1.3 - 2.1 increases: Mg containing antacids and laxatives and renal impairment Decreases: PPIs, diuretics

BMP: Sodium

135 - 145 increases: hypertonic saline decreases: carbamazepine, oxcarbazepine, SSRIs, diuretics

Patients should be monitored how long after a vaccine?

15 minutes

Drugs Used for Anxiety

1st line SSRIs and SNRIs - SSRIs: Escitalopram (Lexapro), Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft) - SNRI's: Duloxetine (Cymbalta), Venlafaxine (Effexor) - Start at 1/2 dose for depression and slowly titrate - Takes at least 4 weeks to see results 2nd Line: - Buspirone: used in combo with antidepressants, takes 2-4 weeks to see effect - Tricyclic antidepressants: Amitriptyline (Elavil) - Hydroxyzine (Vistaril) - Pregabalin (Lyrica) - Gabapentin (Neurontin) Special situations: - Propranolol (Inderal)

BMP: BUN (blood urea nitrogen)

7 - 20 increased in renal impairment and dehydration

USP Chapter 795 USP Chapter 797 USP Chapter 800

795: Non-sterile Preparations 797: Sterile Preparations 800: Hazardous Drugs

BMP Calcium

8.5 - 10.5 mg/dL correct if albumin is low Increase if: calcium supp, vitamin D, thiazide diuretics Decreases if: systemic steroids, long-term heparin, loop diuretics, bisphosphonates, cinacalcet

Lab: Low Density Lipoprotein (LDL)

<100 mg/dL, desirable Fasting 9-12 hrs to draw these Non-HDL = TC - HDL

Lab: Total Cholesterol

<200 mg/dL Fasting 9-12 hrs to draw these Non-HDL = TC - HDL

Hemoglobin A1C

<7% (ADA), </=6.5% (AACE) Average blood glucose over the past 3 months

Lab: High Density Lipoprotein (HDL)

>/= 60 mg/dL desirable Fasting 9-12 hrs to draw these Non-HDL = TC - HDL

Lab: Fasting Plasma Glucose (FPG)

>/=126 is positive for diabetes 100-125 is positive for prediabetes Must be fasting for 8+ hours

Immunosuppression from Steroids

A patient is immunosuppressed when using >/= 2mg/kg/day or >/= 20mg/day of prednisone or prednisone equivalent for >2 weeks Immunosuppressed patients cannot receive live vaccines and have a high risk of infection steroid will need to be slowly tapered off - reduce 10-20% every few days

4 Preferred Drug Classes for Initial and/or Titration of HTN Treatment before other classes

ACEIs or ARB or CCBs or Thiazide diuretics

1st line in CKD?

ACEi or ARBs are first line in pts with CKD diabetes and/or HTN to prevent progression of disease if ALBUMINURIA is present Recommended BP <140/90 and <130/80 (with proteinuria). When starting tx with an ACEi or ARB SCr can increase by up to 30%. This is expected and tx should not be stopped. If SCr increases to > 30% tx should be DCed

KD That Cause or Worsen Depression

ADHD medications: Atomoxetine (Strattera), methylphenidate and other stimulants Analgesics: Indomethacin Antiretrovirals (NNRTI's): Efavirenz, Rilpivirine Cardiovascular meds: BB (especially propranolol) Hormones: hormonal contraceptives, anabolic steroids Others: antidepressants, benzos, systemic steroids, interferons, varenicline, ethanol

Signs and Symptoms of Systolic HF

AKA HFrEF (EF<40%) Labs: increased BNP and NT-proBNP Left-sided signs and symptoms: blood can't get to the body - orthopnea (SOB laying flat) - paroxysmal nocturnal dyspnea (PND): nocturnal cough and SOB - bibasilar rales - S3 gallop - hypoperfusion Right-sided signs and symptoms: blood can't return to the heart so it gets backed up - peripheral edema - ascites - jugular venous distension (JVD) - hepatojugular reflux (HJR) - hepatomegaly General s/sx - dyspnea, cough, fatigue, weakness, reduced exercise capacity

Hand-Foot Syndrome Management

AKA palmar-plantar erythrodysesthesia (PPD) Frequently occurs after tx from capecitabine, fluorouracil, cytarabine, and TKI - limit daily activities to reduce friction and heat exposure to hands and feet - avoid exposure to hot water, take lukewarm showers - avoid use of rubber gloves - avoid increased pressure on soles of feet - avoid increased pressure on hands - emollients (aquaphor), steroids or pain medications

Cleaning the Primary Engineering Controls (PEC)

AKA the sterile hood - cleaned from top to bottom, back to front use wipes and not sprays because sprays can aerosolize hazards drugs previously compounded Air sampling every 6 months Surface sampling: periodically Keep running at all time to help keep clean

Antibiotics with risks for C.diff

ALL antibiotics have a warning for CDI but Clindamycin (Cleocin) has a boxed warning

AUC:MIC Antibiotics

AUC:MIC - Vancomycin - Macrolides - Tetracycline - Polymyxins Goal: Keep AUC over MIC Dosing Strategies variable

KD Drugs Commonly Associated with Severe Skin Reactions

Abacavir Allopurinol Carbamazepine Ethosuximide Lamotrigine Modafinil Nevirapine Penicillin's Phenytoin Sulfamethoxazole see page 973 for others

Glycoprotein IIb/IIIa Receptor Antagonists

Abciximab: ReoPro Eptifibatide: Integrillin Tirofiban: Aggrastat Given for ACS (acute coronary syndrome) MOA: antiplatelet, Glycoprotein IIb/IIIa Receptor Antagonists

Treatment for altitude sickness and motion sickness

Acetazolamide (Diamox) start the day before CI with sulfa allergy

KD Select Drugs That Can Worsen Insomnia

Acetylcholinesterase inhibitors (donepezil) Alcohol Antiretrovirals (emtricitabine, INSTIs) Aripiprazole Atomoxetine Bupropion Caffeine Decongestants (pseudoephedrine) Diuretics (due to nocturia) Fluoxetine (if taken later in the day) Steroids Stimulants (methylphenidate, phentermine) Varenicline

Lab Tests for Liver Disease

Acute liver toxicity, including from drugs - increased AST/ALT Chronic liver disease (cirrhosis) - increased AST/ALT, Alk Phos, Tbili, LDH, PT/INR - decreased albumin Alcoholic liver disease - increases AST > increased ALT (AST will be about double), increased GGT Hepatic encephalopathy - increased ammonia Jaundice - increased Tbili

Sickle Cell Disease Complications

Acute: - acute chest syndrome - anemia - cholecystitis (gallbladder infection) - infection - multiorgan failure (kidneys, liver, lungs) - priapism (pain and prolonged erection) - spleen sequestration - stroke (do not use estrogen contraception, progestin or barrier only) - vaso-occlusive crisis (acute pain crisis) Chronic: - avascular necrosis (bone death) - leg ulcers - gallstones - pain - pregnancy complications - pulmonary HTN - renal impairment - retinopathy - recurrent priapism

Chemotherapy-Induced Nausea and Vomiting Subtypes

Acute: - onset: within 24 hrs after chemo - DT: 5HT3 receptor antagonists (5HT3-RA) "-setron" - DT: NK1 receptor antagonists (NK1-RA) "-pitant" - DT: dexamethasone and olanzapine Delayed: - Onset: >24 hrs after chemo - RF: anthracyclines, platinum analogs, cyclophosphamide, ifosfamide, high NV risk chemo - DT: NK1-RA corticosteroids, palonosetron or granisetron and olanzapine Anticipatory: - Onset: before chemo - DT: benzos, give the evening prior to chemo

When and how to use insulin in T2D

Add basal insulin if above A1C goal after combo therapy (want to try metformin and GLP-1 RA 1st) - start 10 units/day or 0.1 - 0.2 units/kg/day - titrate 2 units every 3 days - if hypoglycemia decrease 10 - 20% if above A1C still add prandial insulin - start one dose with largest meal - start 4 units/day or 10% basal dose - titrate 1 - 2 units increase or 10 - 15% if goal not met - if hypoglycemia decrease dose 10 - 20% if still above A1C goal - add prandial insulin for other meals

Vitamin D deficiency and secondary hyperparathyroidism

After controlling hyperphosphatemia, elevations in PTH are treated primarily with vitamin D. VD deficiency occurs when kidneys cannot activate VD to active form, 1,25-dihydroxy vitamin D. Use these in earlier stages of CKD (3 and 4) Vitamin D3: cholecalciferol (skin) Vitamin D2: ergocalciferol (dietary) Vitamin D analogs for patients in later stages of CKD or ESRD - Calcitriol, Calciferdiol, ect Calcimimetic used only in dialysis pts - Cinacalcet (Sensipar)

KD Select Drugs That Cause Anxiety

Albuterol (if used to frequently or incorrectly) Antipsychotics (ex aripiprazole, haloperidol) Bupropion Caffeine (in high doses) Decongestants (ex pseudoephedrine) Illicit drugs (cocaine, LSD, methamphetamine) Levothyroxine Steroids Stimulants (amphetamine and methylphenidate) Theophylline

Interferon alfa vs beta

Alfa: HBV, HCV and some cancers Beta: multiple sclerosis (MS) Interferons do not provide a cure and are hard to take FLU LIKE SYMPTOMS after the injection is very common

BBW For all Antidepressants

All antidepressants carry a BBW of possible increase in suicidal thoughts or actions in some children, teenagers or young adults within the first few months of treatment.

Antidepressant that does not need to be tapered

All antidepressants need to be tapered besides fluoxetine (prozac) because of its long t1/2 (self tapers)

Drugs with Additive/Adverse Bleeding Risks

Anticoagulants Antiplatelets NSAIDs SSRIs, SNRIs Natural products (5 G's: garlic, ginger, ginkgo, ginseng, and glucosamine)

Injectable Direct Thrombin Inhibitors

Argatroban Bivalirudin (Angiomax) MOA: directly inhibit thrombin Used in pts at risk for HIT

Amikacin

Aminoglycoside antibiotic - DF: IV - MOA: bind to 30S subunit of ribosome to halt protein synthesis - Primarily cover gram - - Concentration depended killing (high Cmax wanted) - Renal dose adjustment for time interval - BBW: nephrotoxicity and ototoxicity - ADE: BBW + vestibular toxicity (balance issues) - Monitor: drug level and renal function

Tobramycin

Aminoglycoside antibiotic - DF: IV, IM, ophthalmic, inhaled - MOA: bind to 30S subunit of ribosome to halt protein synthesis - Primarily cover gram - - Concentration depended killing (high Cmax wanted) - Renal dose adjustment for time interval - BBW: nephrotoxicity and ototoxicity - ADE: BBW + vestibular toxicity (balance issues) - Monitor: drug level and renal function

Genamicin

Aminoglycoside antibiotic -DF:IV, IM, ophthalmic, topical - MOA: bind to 30S subunit of ribosome to halt protein synthesis - Primarily cover gram - - Concentration depended killing (high Cmax wanted) - Renal dose adjustment for time interval - BBW: nephrotoxicity and ototoxicity - ADE: BBW + vestibular toxicity (balance issues) - Monitor: drug level and renal function

KD Select Drugs that Cause Kidney Disease

Aminoglycosides Amphotericin B Cisplatin Cyclosporine Loop diuretics NSAIDS Polymyxins Radiographic contrast dye Tacrolimus Vancomycin

Common Antiarrhythmics

Amiodarone (III), the non-DHP CCBs (diltiazem and verapamil) (IV), digoxin (Na-K-ATPase blocker), and beta-blockers

Common Cardiovascular Drug Interactions

Amiodarone + Warfarin - amio inhibits 2C9 = increased INR - Start Warfarin dose </=5 or decrease 30-50% Amiodarone + digoxin - amio inhibits P-gp = increased risk for bradycardia - decrease digoxin dose 50% Digoxin + loop diuretic - dig toxicity increased with decreased K and Mg Drugs that decrease HR - Non-DPH CCBs, BBs, amiodarone, digoxin, clonidine and dexmedetomidine (precedex) Statins + strong 3A4 inhibitors (G<3PACMAN) - increased level of statins - simvastatin and lovastatin are CI Warfarin + 2C9 inhibitors and inducers

KD that can increase BP

Amphetamines and ADHD drugs Cocaine Decongestants (pseudoephedrine, phenylephrine) Erythropoiesis-stimulating agents Immunosuppressants (cyclosporine) NSAIDs Systemic Steroids Excessive alcohol Appetite suppressants (phentermine) Caffiene Oral contraceptives Antidepressants (TCAs, SNRIs, MAOIs)

Oral Iron DDI

Anatacids, H2RAs and PPIs decrease iron absorption by increasing gastric pH. - take iron 2 hrs before or 4 hrs after antacids - separating admin of H2RAs and PPIs does not improve absorption bc they can increase gastric pH for up to 24s Iron is a polyvalent cation and can decrease absorption of other drugs by binding with them - quinolones and tetracycline antibiotics: take iron 2 hrs before or 4-8 hrs after these agents - bisphosphonates: take iron 60 mins after oral ibandronate or 30 mins after alendronate/risdronate Levothyroxine: separate iron 2-4 hrs

Ascites TX

Ascites: fluid build up in the peritoneal space which can lead to spontaneous bacterial peritonitis (SBP) (TX ceftriaxone 5 - 7 days and albumin) and hepatorenal syndrome (HRS) Many tx approaches - sodium restriction - diuretics (spironolactone monotherapy or combo with furosemide) when used together ratio should be 40 mg furosemide to 100 mg spironolactone All patients with cirrhosis and ascites should be considered for liver transplant

Drugs for Secondary Prevention After Acute Coronary Syndrome (ACS)

Aspirin: 81 mg/day unless CI P2Y12 inhibitor: - Medical therapy patients: (fibrinolytics) ticagrelor or clopidogrel with aspirin for at least 12 months. - PCI-treated: clopidogrel, ticagrelor, or prasugrel with aspirin for at least 12 months Nitroglycerin: indefinitely (SL or spray PRN) Beta-blocker: 3 years; continue indefinitely if HF or if needed for tx of HTN ACE inhibitor: indefinitely if EF < 40%, HTN, CKD, or diabetes; consider for all MI patients with no CI Aldosterone antagonists: - indefinitely if EF </= 40% and either symptomatic HF or DM receiving target doses of ACE I and BB -CI: significant renal impairment (SCr > 2.5 in men and >2 in women) or hyperkalemia (k > 5) Statin: Indefinitely, high intensity statin - pts >/= 75: consider moderate or high intensity statin

Asthma vs COPD drug treatment

Asthma: ICS and ICS/LABA combinations are preferred COPD: LABA, LAMA or LABA/LAMA combinations are preferred

Nicotine Patch Counseling

At the start of the day, remove a new patch from the pouch; save the pouch to use to throw away after Apply to dry hairless skin for about 10 seconds Wear 24 hours, especially if having cravings when you wake up. If having vivid dreams or trouble sleeping remove patch prior to bedtime and apply a new one in the morning. Discard by sticking sticky ends together and placing in pouch in trash can. Do not apply to the same spot for at least one week, rotate. Never cut or wear more than one at a time

High Intensity statins

Atorvastatin (Lipitor) 40-80 mg Rosuvastatin (Crestor) 20-40 mg

Macrolides Overview

Azithromycin (Z-pak), Clarithromycin (Biaxin), Erythromycin (E.E.S, Ery-tab, Erythrocin) - MOA: bind to the 50S ribosomal subunit inhibiting RNA-dependent protein synthesis - Concentration dependent (high Cmax) - Excellent Atypical coverage - Used for community acquired upper and lower respiratory track infections, certain STI's - Can cause QT prolongation, highest risk with erythromycin

Lab: Vitamin B12

B12 and folate are ordered for further workup for MACROcytic anemia decreases: PPIs, metformin, colchicine

Lab: Folic acid (folate)

B12 and folate are ordered for further workup for MACROcytic anemia decreases: phenytoin/fosphenytoin, phenobarbital, primidone, methotrexate, bactrim supplement folate in women of childbearing age and alcoholism

Morphine

BN: (ER: MS Contin, Kadian) (Injection: Duramorph, Infumorph) Opioid Can give diphenhydramine if pruritus occurs.

Aripiprazole

BN: Abilify MOA: second generation antipsychotic (SGA), blocks dopamine (D2) and serotonin (5-HT2A) receptors (by partial agonism). BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics ADE: akathisia, HA, anxiety, sedating or activating, constipation Also approved for irritability with autism and Tourette disorder Can be used alone or in combo with mood stabilizers for bipolar depression for acute mania

Aripiprazole

BN: Abilify Use: antipsychotic and treatment resistant depression BBW: Elderly pts with dementia-related psychosis treated with antipsychotic drugs are at increased risk of death ADE: metabolic issues, anxiety, insomnia, akathisia

Quinapril

BN: Accupril MOA: ACE inhibitor, blocks the conversion of angiotensin 1 to angiotensin 2, resulting in decreased vasoconstriction and decreased aldosterone secretion. They block the degradation of bradykinin which is thought to contribute to the vasodilatory effects (and side effects of dry hacking cough and angioedema) BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected DECREASE MORTALITY AND MORBIDITY IN HF CI: hx of angioedema, within 36 hrs use of sacubitril/valsartan (Entresto) Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal stenosis (avoid use) ADE: generally well tolerated, can cause cough, hyperkalemia, increase SCr, hypotension

Alteplase

BN: Activase MOA: fibrinolytic, cause fibrinolysis (clot breakdown) by binding fibrin and converting plasminogen to plasmin. Used for STEMI only. PCI in preferred if it can be performed within 90 minutes or within 120 minutes of first medical contact. If not possible than fibrinolytic is recommended and should be given within 30 minutes of hospital arrival. CI: ACTIVE INTERNAL BLEEDING, HISTORY OF RECENT STROKE, any prior intracranial hemorrhage (ICH), recent intracranial or intraspinal surgery or trauma in the last 2-3 months, aneurysm, SEVERE UNCONTROLLED HTN ADE: BLEEDING (including ICH) Monitoring: Hgb, Hct, s/sx of bleeding ALTEPLASE CI and dosing differ when used for ischemic stroke

Risedronate

BN: Actonel, Atelvia (only oral) MOA: bisphosphonate for osteoporosis: inhibits osteoclast activity and bone reabsorption. Uses: osteoporosis prevention or tx (1st line), Paget's disease, glucocorticoid-induced osteoporosis (in pts taking >/= 7.5 mg daily of prednisone or equivalent) CI: hypocalcemia, inability to stand or sit upright for at least 30 minutes Warning: ONJ (necrotic jaw), atypical femur fractures, esophagitis/erosions, hypocalcemia Renal impairment: CrCl < 30 do not use ADE: Dyspepsia, dysphagia, heartburn, NV, hypocalcemia

Crinalizumab

BN: Adakveo MOA: used for sickle cell disease, inhibits P-selectin Warning: infusion related reactions

Nifedipine

BN: Adalat, Procardia MOA: dihydropyridine CCB, inhibits Ca ions from entering vascular smooth muscle and myocardial cells and this causes peripheral arterial vasodilation - used in Raynaud's to prevent cold fingers Warning: hypotension ADE: generally well tolerated, peripheral edema, HA, flushing, palpations, reflex tachycardia, gingival hyperplasia DOC in pregnancy DDI: major substrate for 3A4, do not use with grapefruit

Dextroamphetamine/Amphetamine

BN: Adderall MOA: stimulant for ADHD (1st line), blocks reuptake or NE and dopamine. Stimulants do not need to be tapered for DCing BBW: high potential for abuse and dependence. Misuse can cause sudden death and serious CV events CI: within 14 days of a MAOI, heart issues Warnings: increase HR and BP, loss of appetite, risk of serotonin syndrome ADE: insomnia, decreased appetite, HA, irritability

Adenosine

BN: Adenocard MOA: activated adenosine receptors to decrease AV node conduction USES: paroxysmal supraventricular tachyarrhythmias (PSVTs) T1/2: less than 10 sec

Doxorubicin

BN: Adriamycin MOA: anthracycline, Cell Cycle Independent Drug, intercalates DNA inhibiting topoisomerase II and creating oxygen free radicals that damage cells CARDIOTOXICITY: so keep lifetime dose log (MAX 450-550 mg/m^2) Dexrazoxane to prevent cardiotoxicity strong VESICANT Drug is red and causes discoloration of urine, tears, sweat and salvia BBW: myocardial toxicity, vesicant, myelosuppression NV: give antiemetics

Fluorouracil (5-FU)

BN: Adrucil MOA: pyrimidine analog antimetabolite, inhibit pyrimidine synthesis during S phase Give Leucovorin with 5-FU to increase the efficacy BBW: significant increase in INR ADE: HAND-FOOT SYNDROME, diarrhea, mucositis, cardiotoxicity, photosensitivity

Fluticasone + Salmeterol

BN: Advair ICS + LABA

Ibuprofen

BN: Advil, Motrin NSAID

Spironolactone

BN: Aldactone (preferred add on drug for resistant HTN and commonly used in HF) MOA: potassium sparing diuretic, non-selective aldosterone antagonist, compete with aldosterone at the distal convoluted tubule and collecting ducts increasing Na and water excretion conservation K CI: do not use if hyperkalemic, severe renal impairment, Addison's disease ADE: Hyperkalemia, Increased SCr, gynecomastia, breast tenderness, impotence, irregular menses an additional drug for treating HTN often used in combination with hydrochlorothiazide to counteract K losses.

Naproxen

BN: Aleve, Naprosyn NSAID

Sodium Bicarbonate + aspirin + citric acid

BN: Alka-Seltzer Heartburn/GERD

Estradiol

BN: Alora, Climara, Vivelle-Dot (patches) *systemic* Use: menopausal vasomotor symptoms, vaginal atrophy, and osteoporosis prevention. These use estradiol while contraception uses ethinyl estradiol BBW: endometrial cancer (if estrogen used without progestin in women with uterus), dementia (women >/=65), stroke, breast cancer CI: estrogen containing products: breast cancer, undiagnosed uterine bleeding, active VTE, pregnancy Warnings: increase risk of breast cancer ADE: edema, HTN, HA, weight gain, depression, ab pain, N

Palonosetron

BN: Aloxi Use: antiemetic, 1 of CINV combo med MOA: 5HT-3 (serotonin) receptor antagonist CI: do not use with apomorphine due to severe hypotension and loss of consciousness Warnings: dose dependent increase in QT interval (torsades de pointes). Serotonin syndrome when used in combo with other serotonergic agents ADE: HA, constipation

Ramipril

BN: Altace MOA: ACE inhibitor, blocks the conversion of angiotensin 1 to angiotensin 2, resulting in decreased vasoconstriction and decreased aldosterone secretion. They block the degradation of bradykinin which is thought to contribute to the vasodilatory effects (and side effects of dry hacking cough and angioedema) BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected DECREASE MORTALITY AND MORBIDITY IN HF CI: hx of angioedema, within 36 hrs use of sacubitril/valsartan (Entresto) Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal stenosis (avoid use) ADE: generally well tolerated, can cause cough, hyperkalemia, increase SCr, hypotension

Lovastatin

BN: Altoprev, Mevacor (take with evening meal) MOA: inhibits HMG-CoA reductase which prevents the conversion HMG-CoA to mevalonate. CI: do not use in pregnancy or breastfeeding, with liver disease Warnings: muscle damage, increased CPK, acute renal failure ADE: generally well tolerated, myalgias/myopathy Lipid effects: decreases LDL ~ 20 - 55% increases HDL ~ 5 - 15% decreases TG ~ 10 - 30%

Zolpidem

BN: Ambien MOA: hypnotic, non-bzd, acts selectively at the benzodiazepine receptors to increase GABA, an inhibitory neurotransmitter, this causes CNS depression BBW: complex sleep behaviors (sleep walking, sleep driving, ect) can lead to serious injury or death. Warning: increased risk of CNS depression and next day impairment with <7-8 hrs of sleep. Potential abuse and dependence CI: hx of complex sleep behavior ADE: somnolence, dizziness, ataxia, parasomnias C-IV and preferred over benzodiazepines Do not take with fatty food, heavy meal or alcohol

Lubiprostone

BN: Amitiza Chloride channel activator for constipation after OTC trial (CIC, OIC, IBS-C in adult women ONLY) CI: mechanical bowel obstruction

Cyclobenzaprine

BN: Amrix, Fexmid, Flexeril antispasmodic with analgesic effects can worsen cardiac arrhythmias

Testosterone gel

BN: AndroGel Use: hypogonadism in males BBW: secondary exposure to testosterone in children can result in virilization; children should avoid contact with any unwashed or unclothed application sites in men using topical testosterone CI: breast cancer, prostate cancer, pregnancy, breast cancer Warning: increased risk of breast cancer, prostate cancer, CV events, VTE, dyslipidemia, gynecomastia, polycythemia, priapism ADE: increased appetite, acne, edema, hepatotoxicity, reduced sperm count use at same time each morning

fenofibrate, fenofibric acid

BN: Antara, TriCor, Trilipix MOA: fibrate to lower cholesterol: PPAR-alpha activator which leads to increased catabolism of VLDL particles. This is decrease TG significantly but in the setting of high TG fibrate therapy can lead to increased LDL. CI: severe liver disease including primary biliary cirrhosis, severe renal disease (CrCl </= 30), Gallbladder disease Warnings: myopathy, increased risk when with statin ADE: dyspepsia, increased LFTs Lipid effects: decreases TG: ~20 - 50% increases HDL: ~ 15% decreases LDL: ~ 5 - 20% (can increase LDL when TG are high)

Darbepoetin alfa

BN: Aranesp MOA: erythropoiesis stimulating agent Used for normocytic anemia or cancer while taking chemotherapy IV or SQ weekly, initiate when Hgb < 10. Stop when Hgb approaches or exceeds 11 BBW: increased risk of death, MI, stroke, VTE, thrombosis especially when Hgb > 11. For CA not indicated when the anticipated outcome is cure. CI: uncontrolled HTN, pure red blood cell aplasia (PRCA) Warning: HTN, seizures ADE: arthralgia/bone pain Do not shake vial for syringe

Anastrozole

BN: Arimedex MOA: aromatase inhibitor, blocks conversion of androgens to estrogen (not useful for premenopausal women) For breast CA ADE: high risk for osteoporosis, higher risk of CVD compared to SERMs, hot flashes/night sweats, arthralgias/myalgia

Fondaparinux

BN: Arixtra MOA: injectable indirect Xa inhibitor BBW: patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal procedure are at risk for hematomas and subsequent paralysis CI: CrCl < 30

Ipratropium Bromide

BN: Atrovent (short acting anticholinergic for COPD/asthma) MOA: cause bronchodilation by blocking the constricting action of the acetylcholine at M3 muscarinic receptors in the bronchial smooth muscle. Warning: use caution in pts with narrow angle glaucoma, MG, urinary retention, BPH, and bladder neck obstruction ADE: dry mouth, URTI's

Teriflunomide

BN: Aubagio For refractory MS due to toxicities Severe hepatoxicity and teratogencity

Irbesartan

BN: Avapro MOA: ARB, blocks angiotensin 2 from binding receptor on vascular smooth muscle, preventing vasoconstriction BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected ADE: generally well tolerated, can cause cough (less than ACEI), hyperkalemia, increase SCr, hypotension, angioedema (less than ACEI)

Bevacizumab

BN: Avastin MOA: vascular endothelial growth factor (VEGF) inhibitor (inhibits growth of blood vessels) used for certain solid tumors Impairs WOUND HEALING: do not administer for 28 days before and after surgery BBW: severe/fatal bleeding, GI perforation ADE: HTN, proteinuria, thrombosis

Interferon Beta Products

BN: Avonex, Betaseron, ect (QWeek or 3x/week) Peginterferon beta-1a: Plegridy (Q14Day) MOA: alter the expression and response of surface antigens One of the mainstay treatments for pts with relapsing MS Warning: psychiatric disorders, injection site necrosis, increased LFTs, thyroid dysfunction (hyper and hypo). ADE: FLU-LIKE SYMPTOMS

Cyanocobalamin (Vitamin B12)

BN: B-12 Compliance, Nascobal Injection or nasal solution Warning: parenteral products may contain aluminum which can accumulate ADE: pain at injection site Injections 1st line in macrocytic anemia

Entecavir

BN: Baraclude MOA: nucleoside/tide reverse transcriptase inhibitor (NRTI), inhibit HBV replication by inhibiting HBV polymerase resulting in DNA chain termination Prior to starting test for HIV BBW: lactic acidosis and severe hepatomegaly with steatosis, exacerbations of HBV can occur with DCing TAKE ON EMPTY STOMACH ADE: peripheral edema, pyrexia, ascites

Aspirin

BN: Bayer aspirin avoid in children and teens with viral infection due to potential risk of Reye's syndrome. used in ASCVD risk and for the prevention of colorectal CA

Aspirin

BN: Bayer, Bufferin, Ecotrin (75 - 162 Qday) MOA: irreversibly inhibits cyclooxygenase-1 and 2 (COX-1 and 2) enzymes which results in decreased prostaglandin (PG) and thromboxane A2 (TXA2) production. TXA2 is a potent vasoconstrictor and inducer of platelet aggregation. CI: NSAID or salicylate allergy; children and teenagers with viral infections due to risk of Reye's syndrome Warnings: bleeding and tinnitus (salicylate OD) ADE: dyspepsia, heartburn, bleeding, N Use indefinitely in Stable ischemic heart disease (unless CI) Caution with other ototoxic drugs

Suvorexant

BN: Belsomra MOA: for insomnia, orexin receptor antagonist CI: narcolepsy Warnings: abnormal thinking and behavioral changes, worsening depression, suicidal ideation ADE: somnolence

Wheat Dextrin

BN: Benefiber Bulk-forming laxative CI: fecal impaction ADE: farts, ab cramping, bloating Onset: 12 - 72 hours

Olmesartan

BN: Benicar MOA: ARB, blocks angiotensin 2 from binding receptor on vascular smooth muscle, preventing vasoconstriction BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected ADE: generally well tolerated, can cause cough (less than ACEI), hyperkalemia, increase SCr, hypotension, angioedema (less than ACEI)

Belimumab

BN: Benlysta MOA: IgG-lambda Mab prevents the survival or B lymphocytes Warnings: serious sometimes fatal infections, do not give with other biologic DMARDs or live vaccines

Dicyclomine

BN: Bentyl CI: GI obstruction, MG, narrowed angled glaucoma, breastfeeding Warning: anticholinergic effects and can cause toxic megacolon

Carmustine

BN: BiCNU MOA: alkylating agent, Cell Cycle Independent Drug, cross links DNA strands and inhibits protein synthesis. BBW: myelosuppression, pulm toxicity ADE: moderate-high emetic potential, alopecia, secondary malignancies

Hydralazine/Isosorbide Dinitrate

BN: BiDil Indicated for self-identified black patients with NYHA Class III or IV who are symptomatic despite optimal tx with ACE I (or ARB or ARNI), and BB MOA: direct vasodilator for HTN, vasodilates arterioles with little effect on the veins and decreases SVR and BP. CI: mitral valvular rheumatic heart disease, CAD, PDE-5 inhibitors Warning: Drug-induced lupus erythematosus ADE: peripheral edema, HA, flushing, palpitations, reflex tachycardia, NV

Ibandronate

BN: Boniva (oral and IV) MOA: bisphosphonate for osteoporosis: inhibits osteoclast activity and bone reabsorption. Uses: osteoporosis prevention or tx (1st line), Paget's disease, glucocorticoid-induced osteoporosis (in pts taking >/= 7.5 mg daily of prednisone or equivalent) CI: hypocalcemia, inability to stand or sit upright for at least 30 minutes Warning: ONJ (necrotic jaw), atypical femur fractures, esophagitis/erosions (no issue if IV), hypocalcemia Renal impairment: CrCl < 30 do not use ADE: Dyspepsia, dysphagia, heartburn, NV, hypocalcemia IV: acute phase reactions (flu like symptoms)

Fluticasone + Vilanterol

BN: Breo Ellipta ICS + LABA

Esmolol

BN: Brevibloc (injection) MOA: beta-1 selective blocker, decreases HR and myocardial contractility BBW: do not DC abruptly, taper over 1-2 weeks CI: severe bradycardia, 2nd or 3rd degree heart block Warnings: caution in diabetes, can increase or decrease BG and mask hypoglycemic symptoms. ADE: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud's exacerbation

Ticagrelor

BN: Brilinta MOA: antiplatelet prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation. BBW: significant, sometimes fatal bleeding. do not exceed 100 mg of aspirin for maintenance dose. Avoid use when CABG likely, stop 5 days before any surgery CI: active serious bleeding ADE: DYSPENA (>10%), bleeding

Bumetanide

BN: Bumex MOA: block Na and Cl reabsorption in the thick ascending loop of Henle. They increase the excretion Na, K, Cl, Mg, Ca and water. The decrease fluid volume and make it easier for the heart to pump. BBW: can cause profound diuresis resulting in fluid electrolyte depletion CI: anuria Warning: sulfa allergy (not likely to cross react) ADE: decreased electrolytes K, Mg, Na, Cl, Ca - increased: HCO3, UA, BG, TG, total cholesterol - ototoxicity, orthostatic hypotension, photosensitivity Take early in day to avoid nocturia AVOID NSAIDS

Buspirone

BN: Buspar MOA: unknown, used 2nd line in combo with antidepressants for anxiety CI: use within 14 days of MAOI No potential for abuse, tolerance or physical dependence

Buprenorphine

BN: Butrans, Belbuca - partial mu agonists - Warning for QT prolongation

Nebivolol

BN: Bystolic MOA: beta-1 selective blocker with Nitric oxide (NO)-dependent Vasodilation, decreases HR and myocardial contractility BBW: do not DC abruptly, taper over 1-2 weeks CI: Severe liver impairment, severe bradycardia, 2nd or 3rd degree heart block Warnings: caution in diabetes, can increase or decrease BG and mask hypoglycemic symptoms. ADE: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud's exacerbation NO causes peripheral vasodilation

Verapamil

BN: Calan MOA: non-DPH CCB primarily used to control HR in Afib, and sometimes for HTN and angina, inhibits Ca ions from entering vascular smooth muscle and myocardial cells, causing a negative inotropic (decreased force of ventricular contraction) and negative chronotropic (decreased HR) effects CI: hypotension (SBP < 90) or cardiogenic shock; 2nd or 3rd degree AV block or sick sinus syndrome Warnings: may worsen HF symptoms, bradycardia, hypotension ADE: edema, constipations, gingival hyperplasia DDI: major substrate for 3A4, do not use with grapefruit

Calcium Citrate

BN: Calcitrate, Citracal Calcium supplement (21% elemental calcium) for osteoporosis or osteopenia ADE: hypercalcemia, CONSTIPATION, nausea Monitor: Ca, PO4, PTH Take with or without food

Irinotecan

BN: Camptosar MOA: topoisomerase I Inhibitor blocks DNA coiling in S phase BBW: myelosuppression ADE: acute cholinergic symptoms (flushing, sweating, ab cramps, DIARRHEA (tx w/ atropine)), alopecia,

Sucralfate

BN: Carafate Cytoprotective:Treatment for NSAID related peptic ulcer ADE: constipation

Nicardipine IV

BN: Cardene IV MOA: dihydropyridine CCB, inhibits Ca ions from entering vascular smooth muscle and myocardial cells and this causes peripheral arterial vasodilation CI: do not use in advanced aortic stenosis Warning: hypotension ADE: generally well tolerated, peripheral edema, HA, flushing, palpations, reflex tachycardia, gingival hyperplasia DDI: major substrate for 3A4, do not use with grapefruit

Diltiazem

BN: Cardizem, Tiazac MOA: non-DPH CCB primarily used to control HR in Afib, and sometimes for HTN and angina, inhibits Ca ions from entering vascular smooth muscle and myocardial cells, causing a negative inotropic (decreased force of ventricular contraction) and negative chronotropic (decreased HR) effects CI: hypotension (SBP < 90) or cardiogenic shock; 2nd or 3rd degree AV block or sick sinus syndrome Warnings: may worsen HF symptoms, bradycardia, hypotension ADE: edema, constipations, gingival hyperplasia DDI: major substrate for 3A4, do not use with grapefruit

Clonidine

BN: Catapres MOA: alpha-2 agonist, decrease BP by stimulating alpha-2 adrenergic receptors in the brain and reducing sympathetic outflow or norepinephrine, which decreases SVR and HR. Warning: do not DC abruptly can cause rebound HTN, ADE: dry mouth, somnolence, fatigue, dizziness, constipation, decrease HR, hypotension Clonidine patch: skin rash, pruritus, erythema commonly used for resistant HTN and in patients who can not swallow (dysphagia, dementia) since it is available in patch formulation. Apply weekly, remove before MRI

Celecoxib

BN: Celebrex NSAID CI: sulfonamide allergy Highest COX-2 selectivity (lower risk for GI complications but increase risk for stroke/MI

Citalopram

BN: Celexa MOA: SSRI Max dose 40 mg ; 20 mg in > 60 yo (QT prolongation) BBW: possible increase in suicidal thoughts or actions in some children, teenagers or young adults within the first few months of treatment CI: MAOI's, linezolid, IV methylene blue Warning: QT prolongation, SIADH/hyponatremia, fall risk, bleeding ADE: sexual: decreased libido, ejaculation difficulties, ED; somnolence, insomnia, nausea, dry mouth, diaphoresis, weakness, tremor, dizziness, HA

Nabilone

BN: Cesamet MOA: cannabinoid that inhibits vomiting ADE: somnolence, euphoria, increased appetite

Varenicline

BN: Chantix MOA: partial neuronal alpha-4 and beta-2 nicotinic receptor agonist, blocks nicotine's ability to bind. Does not need to be tapered Start 1 week before quit date Warning: serious neuropsychiatric events, seizures, increased effects of alcohol ADE: N (30%), insomnia, abnormal dreams, HA To decrease N take with food or glass of water

Certolizumab pegol

BN: Cimzia MOA: Anti-TNF biologic DMARD BBW: serious infections, malignancies CI: active systemic infection Warnings: demyelinating disease, hep B reactivation, HF, hepatotoxicity, lupus-like syndrome DO NOT use other biologic DMARDs or live vaccines MXT is 1st line and these are add ons

Methylcellulose

BN: Citrucel Bulk-forming laxative CI: fecal impaction ADE: farts, ab cramping, bloating Onset: 12 - 72 hours

Clozapine

BN: Clozaril MOA: second generation antipsychotic (SGA), blocks dopamine (D2) and serotonin (5-HT2A) receptors. USED NO SOONER THAN 3RD LINE DUE TO ADE (most efficacious though) BBW: significant risk for life-threatening neutropenia/agranulocytosis (REMS program) Myocarditis and cardiomyopathy, seizures. Elderly pts with dementia related psychosis: increased risk of death from antipsychotics ADE: Agranulocytosis, seizures, constipation Monitoring: REMS At start of tx ANC must be >/= 1500

Docusate sodium

BN: Colace (+ senna: Senna S, Senokot S) Emollient (stool softener) CI: ab pain, NV, use with mineral oil, OTC use > 1 wk Onset: - oral: 12 - 72 hours - rectal: 2 - 15 minutes Preferred for dry and hard stools and when straining should be avoided.

Colchicine

BN: Colcrys For acute gout attack (can be used for prophylaxis) CI: do not use in combo with P-gp or strong 3A4 inhibitor with renal and/or hepatic impairment Warning: myelosuppression, GI upset, myopathy risk Start within 36 hours of symptom onset.

Prochlorperazine

BN: Compazine Use: antiemetic in CA in low emetic risk MOA: dopamine receptor antagonist in the CNS and chemoreceptor zone BBW: increased mortality in elderly pts with dementia related psychosis Warning: Parkinson disease may be exacerbated ADE: sedation, lethargy, acute EPS, decreased seizure threshold, NMS, anticholinergic effects

Lactulose

BN: Constulose, Enulose) Osmotic laxative CI: low galactose diet ADE: electrolyte imbalance, ab cramping Onset: - oral: 30 mins to 96 hrs - rectal 5 - 30 mins Used commonly for hepatic encephalopathy

Glatiramer acetate

BN: Copaxone MOA: immune modulator for MS Dosing: either daily or 3x/week One of the mainstay treatments for pts with relapsing MS Warning: chest pain ADE: injection site rxns, flushing, diaphoresis, dyspnea PREFERRED TX IF NEEDED DURING PREGNANCY

Carvedilol

BN: Coreg (tab, cap) MOA: non selective BB and alpha-1 blocker, decreases HR and myocardial contractility and decrease peripheral vasoconstriction BBW: do not DC abruptly, taper over 1-2 weeks CI: severe hepatic impairment, severe bradycardia, 2nd or 3rd degree heart block Warnings: caution in diabetes, can increase or decrease BG and mask hypoglycemic symptoms. ADE: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud's exacerbation edema, weight gain 1 OF 3 BB APPROVE FOR CHRONIC HF

Nadolol

BN: Corgard MOA: non-selective (beta-1 and 2 blocker), decreases HR and myocardial contractility BBW: do not DC abruptly, taper over 1-2 weeks CI: severe bradycardia, 2nd or 3rd degree heart block Warnings: caution in diabetes, can increase or decrease BG and mask hypoglycemic symptoms. ADE: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud's exacerbation Non-selective are used in portal hypertension

Warfarin

BN: Coumadin, Jantoven MOA: competitively inhibits C1 subunit of the multi-unit vitamin-K epoxide reductase (VKORC1) enzyme complex) causing depletion of factors II, VII, IX, X and protein C and S Do not double doses on same day if missed Start 10 mg (healthy pts for 1st 2 days) or 5 mg (elderly,, malnourished) BBW: major or fatal bleeding CI: pregnancy (except with mechanical heart valves) Warnings: tissue necrosis/gangrene, HIT, 2C9 substrate ADE: bruising, bleeding, skin necrosis, purple toe syndrome Monitoring: goal INR 2-3 most indications 2.5-3.5 mechanical mitral valve or 2 valves Antidote: vitamin K

Losartan

BN: Cozaar MOA: ARB, blocks angiotensin 2 from binding receptor on vascular smooth muscle, preventing vasoconstriction BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected DECREASE MORTALITY AND MORBIDITY IN HF ADE: generally well tolerated, can cause cough (less than ACEI), hyperkalemia, increase SCr, hypotension, angioedema (less than ACEI)

Rosuvastatin

BN: Crestor (20 - 40 high intensity) MOA: inhibits HMG-CoA reductase which prevents the conversion HMG-CoA to mevalonate. CI: do not use in pregnancy or breastfeeding, with liver disease Warnings: muscle damage, increased CPK, acute renal failure ADE: generally well tolerated, myalgias/myopathy Lipid effects: decreases LDL ~ 20 - 55% increases HDL ~ 5 - 15% decreases TG ~ 10 - 30%

Duloxetine

BN: Cymbalta MOA: SNRI Uses: depression, generalized anxiety disorder, panic disorder, social anxiety disorder CI: MAOIs, linezolid, IV methylene blue Warnings: SIADH/hyponatremia, fall risk, bleeding ADE: sexual: decreased libido, ejaculation difficulties, ED; somnolence, insomnia, nausea, dry mouth, diaphoresis, weakness, tremor, dizziness, HA NE: increased HR, dilated pupils, dry mouth, excessive sweating, and constipation, increase BP DDI: moderate 2D6 inhibitor (so is paroxetine (paxil) and fluoxetine (prozac) those two are SSRIs)

Misoprostol

BN: Cytotec Cytoprotective:Treatment for NSAID related peptic ulcer - BBW: an abortifacient: do not use in women of childbearing age to decrease NSAID ulcers

Cyclophosphamide

BN: Cytoxan MOA: alkylating agent, Cell Cycle Independent Drug, cross links DNA strands and inhibits protein synthesis. Active metabolite Acrolein which concentrated in the bladder and cause hemorrhagic cysts BBW: myelosuppression, hemorrhagic cysts ADE: SIADH, moderate-high emetic potential, alopecia, secondary malignancies Dispense with Mesna to prevent hemorrhagic cysts

Dexamethasone

BN: Decadron Corticosteroid for CINV CI: systemic fungal infections ADE: increased appetite/weight gain, fluid retention, irritability, insomnia, GI upset higher doses can increase BP and BG

Prednisone

BN: Deltasone MOA: glucocorticoid (systemic steroid) Take in morning if QDAY with FOOD CI: live vaccines, serious systemic infections Warning: adrenal suppression: must taper slowly Short-term ADE: increased appetite/weight gain, emotional instability, insomnia, fluid retention, increased intraocular pressure, HTN Long-term ADE: cushing's syndrome

Merperidine

BN: Demerol Opioid Warning: renal impairment/elderly at risk for CNS toxicity. Avoid with or within 2 weeks of an MAOI No longer recommended as an analgesic agent

Testosterone cypionate

BN: Depo-Testosterone (injection) Use: hypogonadism in males BBW: secondary exposure to testosterone in children can result in virilization; children should avoid contact with any unwashed or unclothed application sites in men using topical testosterone CI: breast cancer, prostate cancer, pregnancy, breast cancer Warning: increased risk of breast cancer, prostate cancer, CV events, VTE, dyslipidemia, gynecomastia, polycythemia, priapism ADE: increased appetite, acne, edema, hepatotoxicity, reduced sperm count

Dexamethasone

BN: DexPak, Decadron MOA: glucocorticoid (systemic steroid) Take in morning if QDAY with FOOD CI: live vaccines, serious systemic infections Warning: adrenal suppression: must taper slowly Short-term ADE: increased appetite/weight gain, emotional instability, insomnia, fluid retention, increased intraocular pressure, HTN Long-term ADE: cushing's syndrome

Dexlansoprazole

BN: Dexilant PPI: GERD = 8 week treatment course and then evaluate need for maintenance therapy. Warnings: - C.diff, hypomagnesia, vitamin B12 deficiency associated with use > 2 years, osteoporosis bone fracture with high does > 1 year use Can open capsule and mix with apple sauce Inhibits: 2C19

Digoxin

BN: Digitek, Digox, Lanoxin MOA: inhibits Na-K- ATPase pump causing a positive inotropic effect (increase in CO) and a negative chronotrophy (decreased HR). Does not improve survival in HF, but improves quality of life. Commonly used as an antiarrhythmic CI: ventricular fibrillation Monitoring: electrolytes, renal function, HR Toxicity: NV, loss of appetite, bradycardia, blurred/double vision, greenish-yellow halos Antidote: DigiFab DDI: Reduce digoxin dose 50% when starting amiodarone Not usually given alone for rate control (used in combo with BB or CCB)

Hydromorphone

BN: Dilaudid, Exalgo Opioid

Valsartan

BN: Diovan MOA: ARB, blocks angiotensin 2 from binding receptor on vascular smooth muscle, preventing vasoconstriction BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected DECREASE MORTALITY AND MORBIDITY IN HF ADE: generally well tolerated, can cause cough (less than ACEI), hyperkalemia, increase SCr, hypotension, angioedema (less than ACEI)

Methadone

BN: Dolophine, Methadose Opioid BBW: same as all opioids + life threatening QT prolongation and serious arrhythmias. warning; MAOI's and serotonic drugs can increase the risk of serotonin syndrome. Major 3A4 substrate

Dimenhydrinate

BN: Dramamine - antihistamine for motion sickness.

Meclizine

BN: Dramamine All Day Less Drowsy - antihistamine for motion sickness. - commonly used for vertigo too

Hydroxyurea

BN: Droxia, Hydrea MOA: used for sickle cell, a disease modifying drug that stimulates production of HgbF. Long term use of hydroxyurea reduces the frequency of acute pain crises, episodes of acute chest syndrome and the need for blood transfusions Indicated for adults with >/=3 moderate to severe sickle cell pain crises in one year. Consider use in all children > 9 months regardless of disease severity BBW: myelosuppression, malignancies Warnings: fetal toxicity, avoid live vaccinations ADE: increased LFTs, uric acid, BUN and SCr; mouth ulcers, alopecia, NVD Monitor: CBC with differential Notes: contraception required hazardous drug wear gloves when dispensing and wash hands before and after contact folic acid supplementation to prevent macroocytosis DDI: do not use with other drugs that cause myelosuppression

Conjugated Estrogens/Bazedoxifene

BN: Duavve MOA: horse urine estrogen/SERM combo for osteoporosis prevention in women with a uterus) BBW: endometrial cancer; increased risk of DVT and stroke, dementia CI: breast cancer (any hx), pregnancy, undiagnosed uterine bleeding, hx or active VTE Warning: increased risk of breast cancer and ovarian cancer ADE: ND, dyspepsia, ab pain, muscle spasms Not recommended for women > 75 yo Use estrogen containing products for the shortest duration possible

Bisacodyl

BN: Dulcolax Stimulant laxative First line for OIC Warning: avoid use with stomach pain, NV or a sudden change in bowel movements ADE: ab cramping, electrolyte imbalance Onset: - oral: 6 - 12 hours - rectal: 15 - 60 mins Take stimulant laxative at night

Mometasone + Formoterol

BN: Dulera ICS + LABA

Fentanyl

BN: Duragesic, Sublimaze Opioid - Not for use in opioid naïve patients (need to be on morphine 60 mg/day or equivalent for at least 7 days.

Triamterene

BN: Dyrenium (+HCTZ Dyazide, Maxzide) MOA: potassium sparing diuretic, non-selective aldosterone antagonist, compete with aldosterone at the distal convoluted tubule and collecting ducts increasing Na and water excretion conservation K BBW: hyperkalemia >5.5 CI: do not use if hyperkalemic, severe renal impairment ADE: Hyperkalemia, Increased SCr an additional drug for treating HTN often used in combination with hydrochlorothiazide to counteract K losses.

Venlafaxine

BN: Effexor MOA: SNRI Uses: depression, generalized anxiety disorder, panic disorder, social anxiety disorder CI: MAOIs, linezolid, IV methylene blue Warnings: SIADH/hyponatremia, fall risk, bleeding, additive QT prolongation ADE: sexual: decreased libido, ejaculation difficulties, ED; somnolence, insomnia, nausea, dry mouth, diaphoresis, weakness, tremor, dizziness, HA NE: increased HR, dilated pupils, dry mouth, excessive sweating, and constipation, increase BP

Prasugrel

BN: Effient MOA: antiplatelet prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation. BBW: Significant sometimes fatal bleeding, not recommended in pts >/= 75 yo, do not initiate if CABG likely, stop at least 7 days prior to elective surgery CI: serious bleeding, history of TIA or stroke ADE: generally well tolerated unless bleeding occurs Dispense in original container to protect from moisture Requires a one time loading dose

Amitripyline

BN: Elavil MOA: TCA, primarily inhibit NE and 5-HT reuptake. They also block ACh and histamine receptors. CI: MAOI's, linezolid, IV methylene blue, MI ADE: QT prolongation with OD, suicidal ideation, orthostasis - anticholinergic: dry mouth,, blurred vision, urinary retention, constipation, vivid dreams, weight gain, falls Tertiary Amines: slightly more effective but more anticholinergic properties (more likely to cause sedation and weight gain).

Apixaban

BN: Eliquis MOA: DIRECT factor Xa inhibitors and is only available orally Nonvalvular Afib (stroke prophylaxis): 5mg BID Unless pt has two of the following: >/=80, BW<60kg, or SCr>/=1.5 then give 2.5mg BID TX of DVT/PE: 10mg BIDX7 days, then 5mg BID BBW: patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal procedure are at risk for hematomas and subsequent paralysis CI: active pathological bleeding Warning: not recommended for prosthetic heart valves No monitoring required Antidote: andexanet alfa (Andexxa)

Theophylline

BN: Elixophyllin, Theo-24 Requires IBW based loading dose TR: 5 - 15 mcg/ml MOA: blocks phosphodiesterase, causing an increase in the cyclic adenosine monophosphate (cAMP). Warning: can exacerbate cardiovascular arrhythmias, peptic ulcer disease and seizure disorders ADE: NV, HA, insomnia, tachycardia, tremor, nervousness Toxicity: persistent vomiting, arrhythmias, seizures DDI: major substrate for CYP1A2; inhibitors can increase levels (cimetidine, ciprofloxacin, zileuton) -MANY DDI pg 600

Aprepitant

BN: Emend (cap, suspension, injection) Use: 1 of CINV combo med MOA: substance P/neurokinin-1 receptor antagonist (NK1-RA). ADE: not significant 3A4 inhibitor

Fosaprepitant

BN: Emend (injection) Use: 1 of CINV combo med MOA: substance P/neurokinin-1 receptor antagonist (NK1-RA). ADE: not significant 3A4 inhibitor

Etanercept

BN: Enbrel (weekly) MOA: Anti-TNF biologic DMARD BBW: serious infections, malignancies CI: active systemic infection Warnings: demyelinating disease, hep B reactivation, HF, hepatotoxicity, lupus-like syndrome DO NOT use other biologic DMARDs or live vaccines MXT is 1st line and these are add ons

L-Glutamine

BN: Endari used to reduce acute complications or sickle cell disease ADE: constipation, farts

Acetaminophen + Oxycodone

BN: Endocet, Percoset

Alvimopan

BN: Entereg Peripherally-acting Mu opioid receptor antagonist (PAMORA) for constipation - for hospitalized patients to reduce the risk of operative ileus BBW: potential risk of MI with long-term use (use short term) CI: therapeutic doses of opioids for > 7 consecutive days

Sacubitril/Valsartan

BN: Entresto MOA: combo neprilysin inhibitor (sacubitril) and ARB (valsartan) Indicated for NYHA Class II-IV patients to reduce HF hospitalizations and CV death and possibly 1st line for symptomatic HF patients who cannot tolerate ACE or ARB therapy BBW: injury and death to fetus, stop as soon as pregnancy detected. CI: do not use within 36 hrs of ACE I or hx of angioedema - do not use aliskiren with diabetes Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal stenosis (avoid use) ADE: generally well tolerated, cough, hyperkalemia, increased SCr, hypotension Do not use with ACE or ARB

Sofosbuvir + Velpatasvir

BN: Epclusa MOA: direct acting antivirals: NS5A (replication complex inhibitor) and NS5B (polymerase inhibitor) BBW: risk of reactivating HBV; test all pts for HBV before starting DAA Warning: do not use sofosbuvir and amiodarone (serious bradycardia risk) ADE: well tolerated Avoid acid suppressive therapy Approved for all 6 HCV genotypes DDI: CI with strong inducers of 3A4. Antacids, H2RAs and PPIs can decrease concentrations of ledipasvir and velpatasvir. dispense in original container

Epoetin alfa

BN: Epogen, Procrit MOA: erythropoiesis stimulating agent Used for normocytic anemia or cancer while taking chemotherapy IV or SQ 3x week, initiate when Hgb < 10. Stop when Hgb approaches or exceeds 11 BBW: increased risk of death, MI, stroke, VTE, thrombosis especially when Hgb > 11. For CA not indicated when the anticipated outcome is cure. CI: uncontrolled HTN, pure red blood cell aplasia (PRCA) Warning: HTN, seizures ADE: arthralgia/bone pain Do not shake vial for syringe

Cetuximab

BN: Erbitux MOA: epidermal growth factor receptor (EGFR) inhibitor BBW: severe/fatal infusion-related reactions, cardiac arrest ADE: acneiform rash, serious skin toxicities - rash indicates pt will probably have a better response avoid sunlight, use sunscreen

Progestin Only Pills

BN: Errin, Camila, Nora-BE Contain no estrogen Primarily used in women who are breast feeding because estrogen decreases milk production and its not safe to use estrogen after pregnancy because of the increased chance of clots. Requires good adherence, needs to be taken within the same three hours of scheduled time Progestin ADE: breast tenderness, HA, fatigue, changes in mood. if late cycle breakthrough bleeding occurs an increase progestin dose may be needed

17-Beta-estradiol

BN: Estrace (vag cream), Estring (vag ring), Vagifem (vag tab), PO systemic available too. Use: menopausal vasomotor symptoms, vaginal atrophy, and osteoporosis prevention. These use estradiol while contraception uses ethinyl estradiol Local products may reduce systemic ADE BBW: endometrial cancer (if estrogen used without progestin in women with uterus), dementia (women >/=65), stroke, breast cancer CI: estrogen containing products: breast cancer, undiagnosed uterine bleeding, active VTE, pregnancy Warnings: increase risk of breast cancer ADE: edema, HTN, HA, weight gain, depression, ab pain, N

Romosozumab

BN: Evenity For osteoporosis in postmenopausal females

Raloxifene

BN: Evista MOA: SERM for prevention and tx of osteoporosis; estrogen agonist/antagonist, that decreases bone reabsorption BBW: increased risk of VTE (PE/DVT), increased risk of death due to stroke in women with CHD CI: hx of current VTE or pregnancy ADE: hot flashes, peripheral edema, arthralgia, leg cramps/muscle spasms Separate raloxifene and levothyroxine by several hours if on both, DC 72 hours prior to and during prolonged immobilization

Senna

BN: Ex-lax, Senokot (+ docusate: Senna S, Senokot S) Stimulant laxative First line for OIC Warning: avoid use with stomach pain, NV or a sudden change in bowel movements ADE: ab cramping, electrolyte imbalance Onset: - oral: 6 - 12 hours - rectal: 15 - 60 mins Take stimulant laxative at night

Acetaminophen + Caffeine

BN: Excedrin Tension Headache

Fulvestrant

BN: Faslodex used for breast CA MOA: SERM, estrogen antagonist in breast tissue. CDK4/6 inhibitor BBW: increased risk of thromboembolic events ADE: hot flashes/night sweats, vaginal bleeding/spotting, vaginal discharge/dryness/pruritus, decreases libido

Ferrous Sulfate

BN: FeroSul, Fer-In-Sol Dose: 325 mg (65 mg elemental iron) PO QD-TID Most commonly prescribed and least expensive For iron deficiency anemia and normocytic anemia BBW: accidental OD of iron containing products is the leading cause of fatality in children. CI: hemolytic anemia, hemochromatosis ADE: constipation (dose related), dark and tarry stools Docusate (stool softener) often recommended for constipation Antidote for OD: deferoxamine (Desferal)

Ferrous Fumarate

BN: Ferretts, Ferrimin Dose: 324 mg (106 mg elemental iron) PO QD-TID For iron deficiency anemia and normocytic anemia BBW: accidental OD of iron containing products is the leading cause of fatality in children. CI: hemolytic anemia, hemochromatosis ADE: constipation (dose related), dark and tarry stools Docusate (stool softener) often recommended for constipation Antidote for OD: deferoxamine (Desferal)

Calcium Polycarbophil

BN: FiberCon Bulk-forming laxative CI: fecal impaction ADE: farts, ab cramping, bloating Onset: 12 - 72 hours

Glycerin

BN: Fleet Liquid Glycerin Supp, Pedialax Osmotic laxative ADE: electrolyte imbalance, ab cramping Onset: - oral: 30 mins to 96 hrs - rectal 5 - 30 mins Commonly used in children who need to defecate quickly.

Sodium phosphates

BN: Fleet enema Osmotic laxative ADE: electrolyte imbalance, ab cramping Onset: - oral: 30 mins to 96 hrs - rectal 5 - 30 mins

Fluticasone Inhaled

BN: Flovent, Arnuity ICS

Dexmethylphenidate

BN: Focalin MOA: stimulant for ADHD (1st line), blocks reuptake or NE and dopamine. Stimulants do not need to be tapered for DCing BBW: high potential for abuse and dependence CI: within 14 days of a MAOI, heart issues Warnings: increase HR and BP, loss of appetite, risk of serotonin syndrome ADE: insomnia, decreased appetite, HA, irritability

Teriparatide

BN: Forteo (injection) MOA: analog of parathyroid hormone which stimulates osteoblast activity and increases bone formation (for osteoporosis when there is a very high risk of fracture BBW: osteosarcoma (bone cancer) Warnings: hypercalcemia, orthostatic hypotension ADE: arthralgias, leg cramps, N, orthostasis/dizziness Cumulative treatment duration: 2 years or less due to safety issues

Alendronate

BN: Fosamax (only oral) MOA: bisphosphonate for osteoporosis: inhibits osteoclast activity and bone reabsorption. Uses: osteoporosis prevention or tx (1st line), Paget's disease, glucocorticoid-induced osteoporosis (in pts taking >/= 7.5 mg daily of prednisone or equivalent) CI: hypocalcemia, inability to stand or sit upright for at least 30 minutes Warning: ONJ (necrotic jaw), atypical femur fractures, esophagitis/erosions, hypocalcemia Renal impairment: CrCl < 35 do not use ADE: Dyspepsia, dysphagia, heartburn, NV, hypocalcemia

Ziprasidone

BN: Geodon (take with food) MOA: second generation antipsychotic (SGA), blocks dopamine (D2) and serotonin (5-HT2A) receptors. BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics CI: QT prolongation ADE: somnolence, EPS, dizziness, nausea Can be used alone or in combo with mood stabilizers for bipolar depression for acute mania

Fingolimod

BN: Gilenya For refractory MS due to toxicities Can cause bradycardia, pt must be monitored for at least 6 hrs, EKG at baseline CI in pts with hx of CVD or stroke

Imatinib

BN: Gleevec (TKI are oral) MOA: tyrosine kinase inhibitor, BCR-ABL inhibitor, used in chronic myelogenous leukemia (CML) Must be PHILADELPHIA CHROMOSOME (BCR-ABL) positive to use ADE: FLUID RETENTION, edema, myelosuppression, NVD

Haloperidol

BN: Haldol MOA: first generation antipsychotic (FGA), work mainly by blocking dopamine-2 receptors (D2), with minimal serotonin (5-HT2A) receptor blockade BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics Warnings: QT prolongation, anticholinergic effects, CNS depression, EPS, hyperprolactinemia, NMS ADE: sedation, dizziness, anticholinergic effects

Trastuzumab

BN: Herceptin MOA: human epidermal growth factor receptor 2 (HER2) inhibitor Monitor: LVEF using MUGA scan BBW: heart failure, embryo-fetal death, not interchangeable with other version ADE: NVD, alopecia

Adalimumab

BN: Humira MOA: Anti-TNF biologic DMARD BBW: serious infections, malignancies CI: active systemic infection Warnings: demyelinating disease, hep B reactivation, HF, hepatotoxicity, lupus-like syndrome DO NOT use other biologic DMARDs or live vaccines MXT is 1st line and these are add ons

Ifosfamide

BN: Ifex MOA: alkylating agent, Cell Cycle Independent Drug, cross links DNA strands and inhibits protein synthesis. Active metabolite Acrolein which concentrated in the bladder and cause hemorrhagic cysts BBW: myelosuppression, hemorrhagic cysts, neurotoxicity ADE: moderate-high emetic potential, alopecia, secondary malignancies Dispense with Mesna to prevent hemorrhagic cysts

Loperamide

BN: Imodium A-D Antidiarrheal BBW: torsades de pointes, cardiac arrest and sudden death with doses higher than recommended CI: acute dysentary (blood diarrhea and high fever), pseudomembranous colitis (C. diff), bacterial enterocolitis ADE: constipation, QT prolongation Do not use for > 48 hours for self-treatment

Propranolol

BN: Inderal LA (tab, cap, solution, injection MOA: non-selective (beta-1 and 2 blocker), decreases HR and myocardial contractility BBW: do not DC abruptly, taper over 1-2 weeks CI: severe bradycardia, 2nd or 3rd degree heart block Warnings: caution in diabetes, can increase or decrease BG and mask hypoglycemic symptoms. ADE: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud's exacerbation - Crosses BBB because its high lipid solubility so more CNS side effects than other beta-blockers. Can be useful in migraine prophylaxis Non-selective are used in portal hypertension

Indomethacin

BN: Indocin NSAID

Valbenazine

BN: Ingrezza MOA: for tardive dyskinesia, reversibly inhibits vesicular monoamine transporter 2 (VMAT2) Warning: somnolence

Eplerenone

BN: Inspra MOA: potassium sparing diuretic, selective aldosterone antagonist, compete with aldosterone at the distal convoluted tubule and collecting ducts increasing Na and water excretion conservation K CI: do not use if hyperkalemic, severe renal impairment ADE: Hyperkalemia, Increased SCr, increased TGs an additional drug for treating HTN often used in combination with hydrochlorothiazide to counteract K losses.

Eprifibatide

BN: Integrilin MOA: antiplatelet, Glycoprotein IIb/IIIa Receptor Antagonists CI: thrombocytopenia (platelets <100,000). active internal bleeding, severe uncontrolled HTN, dependent on renal dialysis. ADE: bleeding, thrombocytopenia

Interferon Alfa

BN: Interferon-alfa-2b (Intron A) (for HBV, HCV and CA) Pegylated interferon-alfa-2a (Pegasys) (for HBV and HCV) MOA: interferons are naturally-produced cytokines that have antiviral, antiproliferative and immunomodulatory effects. SC dosing 3 x week and pegylated weekly BBW: neuropsychiatric, autoimmune, ischemic or infectious disorders ADE: CNS effects (fatigue, depression), GI upset, increased LFTs, FLU LIKE SYMPTOMS (pretreat with APAP and an antihistamine) HCV no longer recommend using interferon but PREFERRED FOR HBV as monotherapy

Guanfacine ER

BN: Intuniv MOA: alpha-2 agonist, decrease BP by stimulating alpha-2 adrenergic receptors in the brain and reducing sympathetic outflow or norepinephrine, which decreases SVR and HR. Warning: do not DC abruptly can cause rebound HTN, ADE: dry mouth, somnolence, fatigue, dizziness, constipation, decrease HR, hypotension

Paliperidone

BN: Invega (injection every 3 months, also PO) MOA: second generation antipsychotic (SGA), blocks dopamine (D2) and serotonin (5-HT2A) receptors. BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics ADE: increased prolactin, sexual dysfunction, galactorrhea, irregular periods, EPS, metabolic syndrome (increased weight, BG, lipids)

Monophasic Combination Oral Contraceptives

BN: Junel Fe 1/20, Microgestin Fe 1/20, Sprintec 28, Loestrin 1/20, Yasmin 28, Loestrin 24, Yaz, Lo Loestrin Fe Same dose of estrogen and progesterone throughout the pill pack usually ethinyl estradiol (EE), and progestin (norethindrone, levonorgestrel, drospirenone) Estrogen ADE: N, breast tenderness/fullness, bloating, weight gain, elevated BP - severe: thrombosis, stroke, DVT, MI Progestin ADE: breast tenderness, HA, fatigue, changes in mood. if late cycle breakthrough bleeding occurs an increase progestin dose may be needed BBW: do not use in women > 35 y/o who smoke due to risk of serious CV events

Triamcinolone

BN: Kenalog MOA: glucocorticoid (systemic steroid) Take in morning if QDAY with FOOD CI: live vaccines, serious systemic infections Warning: adrenal suppression: must taper slowly Short-term ADE: increased appetite/weight gain, emotional instability, insomnia, fluid retention, increased intraocular pressure, HTN Long-term ADE: cushing's syndrome

Clonazepam

BN: Klonopin MOA: enhance GABA, an inhibitory neurotransmitter, which caused CNS depression resulting in anxiolytic, anticonvulsant, sedative and/or muscle relaxant properties BBW: use with opioids can result in sedation, resp depression, coma and death. CI: SEVERE LIVER DISEAES (also for diazepam), acute narrow-angled glaucoma, sleep apnea, resp depression Warning: dependence and tolerance, do not DC abruptly. CNS depression, crosses placenta ADE: somnolence dizziness, ataxia C-IV Antidote: Flumazenil

Potassium Chloride

BN: Klor-Con, K-tab Used often in HF Mg should be checked and corrected prior to correcting potassium level bc hypomagnesia can aggravate hypokalemia. CI: severe renal impairment, hyperkalemia ADE: ab pain, cramping, DN, farts, hyperkalemia

Furosemide

BN: Lasix MOA: block Na and Cl reabsorption in the thick ascending loop of Henle. They increase the excretion Na, K, Cl, Mg, Ca and water. The decrease fluid volume and make it easier for the heart to pump. BBW: can cause profound diuresis resulting in fluid electrolyte depletion CI: anuria Warning: sulfa allergy (not likely to cross react) ADE: decreased electrolytes K, Mg, Na, Cl, Ca - increased: HCO3, UA, BG, TG, total cholesterol - ototoxicity, orthostatic hypotension, photosensitivity Take early in day to avoid nocturia AVOID NSAIDS

Lurasidone

BN: Latuda MOA: second generation antipsychotic (SGA), blocks dopamine (D2) and serotonin (5-HT2A) receptors. BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics CI: strong CYP3A4 inhibitors or inducers ADE: somnolence, EPS, nausea Nearly weight, lipid and BG neutral Can be used alone or in combo with mood stabilizers for bipolar depression for acute mania

Escitalopram

BN: Lexapro MOA: SSRI Max dose 10 mg in elderly (QT prolongation) BBW: possible increase in suicidal thoughts or actions in some children, teenagers or young adults within the first few months of treatment CI: MAOI's, linezolid, IV methylene blue Warning: QT prolongation, SIADH/hyponatremia, fall risk, bleeding ADE: sexual: decreased libido, ejaculation difficulties, ED; somnolence, insomnia, nausea, dry mouth, diaphoresis, weakness, tremor, dizziness, HA

Linaclotide

BN: Linzess Guanylate Cyclase C Agonist for CIC and IBS-C BBW: do not use in pediatric pts; high risk of dehydration that can cause death CI: age < 6 y/o, mechanical bowel obstruction

Baclofen

BN: Lioresal antispasmodic with analgesic effects BBW: abrupt withdrawal of intrathecal baclofen can cause rebound spasticity leading to organ failure and death

Atorvastatin

BN: Lipitor (+ amlodipine = Caduet) 40 - 80 mg = high intensity statin (take anytime of day) MOA: inhibits HMG-CoA reductase which prevents the conversion HMG-CoA to mevalonate. CI: do not use in pregnancy or breastfeeding, with liver disease Warnings: muscle damage, increased CPK, acute renal failure ADE: generally well tolerated, myalgias/myopathy Lipid effects: decreases LDL ~ 20 - 55% increases HDL ~ 5 - 15% decreases TG ~ 10 - 30%

Lithium

BN: Lithobid MOA: mood stabilizer used for bipolar depression and/or mania, proposed to work by influencing the reuptake of serotonin and/or norepinephrine or by moderating glutamate levels in the brain. Therapeutic range: 0.6 - 1.2 mEq/L trough BBW: monitor serum lithium to avoid toxicity Warning: serotonin syndrome ADE: GI upset, cognitive effects, cogwheel rigidity, tremor, thirst, polyuria/polydipsia, weight gain, hypothyroidism Toxicity: ataxia, course hand tremor, vomiting, CNS depression, arrhythmia, seizure, coma Monitoring: lithium levels, renal function, thyroid function Renally cleared, avoid in pregnancy DDI: increases lithium: decreases salt in take, NSAIDs decreases lithium: increases salt in take, - SSRI, SNRI, triptans, linezolid can increase risk of serotonin syndrome

Diphenoxylate + atropine

BN: Lomotil Antidiarrheal CI: risk of resp depression and CNS depression in children ADE: atropine (anticholinergic), diphenoxylate (mild euphoria)

Gemfibrozil

BN: Lopid MOA: fibrate to lower cholesterol: PPAR-alpha activator which leads to increased catabolism of VLDL particles. This is decrease TG significantly but in the setting of high TG fibrate therapy can lead to increased LDL. CI: severe liver disease including primary biliary cirrhosis, severe renal disease (CrCl </= 30), Gallbladder disease DO NOT GIVE WITH EZETIMIBE OR STATINS (increases risk of myopathy or rhabdo) Warnings: myopathy, increased risk when with statin ADE: dyspepsia, increased LFTs Lipid effects: decreases TG: ~20 - 50% increases HDL: ~ 15% decreases LDL: ~ 5 - 20% (can increase LDL when TG are high)

Metoprolol Tartrate

BN: Lopressor (tab BID or injection) MOA: beta-1 selective blocker, decreases HR and myocardial contractility BBW: do not DC abruptly, taper over 1-2 weeks CI: severe bradycardia, 2nd or 3rd degree heart block Warnings: caution in diabetes, can increase or decrease BG and mask hypoglycemic symptoms. ADE: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud's exacerbation When switching from tartrate to succinate the same dose of metoprolol should be used

Acetaminophen + Hydrocodone

BN: Lorcet, Lortab, Norco, Vicodin

Benazepril

BN: Lotensin MOA: ACE inhibitor, blocks the conversion of angiotensin 1 to angiotensin 2, resulting in decreased vasoconstriction and decreased aldosterone secretion. They block the degradation of bradykinin which is thought to contribute to the vasodilatory effects (and side effects of dry hacking cough and angioedema) BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected CI: hx of angioedema, within 36 hrs use of sacubitril/valsartan (Entresto) Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal stenosis (avoid use) ADE: generally well tolerated, can cause cough, hyperkalemia, increase SCr, hypotension

Omega-3 Acid Ethyl Esters

BN: Lovaza MOA: unknown but indicated as adjunct to diet when TG >/= 500 (EPA and DHA) Warning: caution in patients with fish/shellfish allergies ADE: eructation (burping), dyspepsia, taste perversions Lipid Effects: decreased TG: ~ 45% increases HDL ~ 9% can increase LDL up to 44% (only lovaza, not seen with Vascepa) DDI: can prolong bleeding time

Eszopiclone

BN: Lunesta MOA: hypnotic, non-bzd, acts selectively at the benzodiazepine receptors to increase GABA, an inhibitory neurotransmitter, this causes CNS depression BBW: complex sleep behaviors (sleep walking, sleep driving, ect) can lead to serious injury or death. Warning: increased risk of CNS depression and next day impairment with <7-8 hrs of sleep. Potential abuse and dependence CI: hx of complex sleep behavior ADE: somnolence, dizziness, ataxia, parasomnias C-IV and preferred over benzodiazepines Do not take with fatty food, heavy meal or alcohol

Leuprolide

BN: Lupron Depot MOA: gonadotropin-releasing hormone agonist reduces testosterone through negative feedback. Initial surge can cause "tumor flare" so give antiandrogen initially for several weeks. USE: prostate CA ADE: decreased bone density (supplement), tumor flare (use antiandrogen: bicalutamide), hot flashes, impotence, gynecomastia, bone pain CI: pregnancy, breastfeeding

Dronabiniol

BN: Marinol MOA: cannabinoid that inhibits vomiting ADE: somnolence, euphoria, increased appetite

Glecaprevir + Pibrentasvir

BN: Mavyret MOA: direct acting antivirals: NS5A (replication complex inhibitor) and NS3/4A protease inhibitor BBW: risk of reactivating HBV; test all pts for HBV before starting DAA ADE: well tolerated Avoid acid suppressive therapy Approved for all 6 HCV genotypes DDI: CI with strong inducers of 3A4. Antacids, H2RAs and PPIs can decrease concentrations of ledipasvir and velpatasvir. Do not use with efavirenz, HIV protease inhibitors, ethinyl estradiol-containing products and cyclosporine.

Methylprednisolone

BN: Medrol, Solu-Medrol MOA: glucocorticoid (systemic steroid) Take in morning if QDAY with FOOD CI: live vaccines, serious systemic infections Warning: adrenal suppression: must taper slowly Short-term ADE: increased appetite/weight gain, emotional instability, insomnia, fluid retention, increased intraocular pressure, HTN Long-term ADE: cushing's syndrome

Psyllium

BN: Metamucil Bulk-forming laxative CI: fecal impaction and GI obstruction ADE: farts, ab cramping, bloating Onset: 12 - 72 hours

Calcitonin

BN: Miacalcin (nasal spray and injection) MOA: for osteoporosis in women > 5 years postmenopause; inhibits bone reabsorption by osteoclasts (rarely used for this indication) Warnings: hypocalcemia (associated with tetany and seizures), increased risk of malignancy, hypersensitivity to salmon-derived products ADE: back pain, myalgia, N, dizziness Can used in management of hypercalcemia of malignancy

Hydrocholorthiazide

BN: Microzide MOA: thiazide diuretic inhibits sodium reabsorption in the distal convoluted tubule, causing increased excretion of Na, Cl, water and K. CI: hypersensitivity to sulfonamide-derived drugs ADE: decreases electrolytes (K, Mg, Na). Can increase Ca, UA, LDL, TG, BG. Photosensitivity Monitor: electrolytes and renal function, BP, fluid status Thiazides are not effective when CrCl < 30 Take early and avoid night doses Chlorthalidone is the only thiazide available IV DDI: NSAIDs can cause water and Na retention and decrease the effectiveness of thiazide. Thiazides decrease lithium renal clearance and increase risk of lithium toxicity.

Acetaminophen + Caffeine + Pyrilamine

BN: Midol

Magnesium Hydroxide

BN: Milk of Magnesia (+ aluminum and simethicone: Mylanta classic) Heartburn/GERD - aluminum and magnesium can accumulate with severe renal dysfunction (not recommended if CrCl < 30) - Magnesium: Can cause loose stools - Aluminum: constipation

Magnesium hydroxide

BN: Milk of magnesia Osmotic laxative Caution with renal impairment and do not use with sever impairment ADE: electrolyte imbalance, ab cramping Onset: - oral: 30 mins to 96 hrs - rectal 5 - 30 mins

Prednisolone

BN: Millipred, Orapred ODT MOA: glucocorticoid (systemic steroid) Take in morning if QDAY with FOOD CI: live vaccines, serious systemic infections Warning: adrenal suppression: must taper slowly Short-term ADE: increased appetite/weight gain, emotional instability, insomnia, fluid retention, increased intraocular pressure, HTN Long-term ADE: cushing's syndrome

Polyethylene glycol 3350

BN: Miralax Osmotic laxative CI: GI obstruction ADE: electrolyte imbalance, ab cramping Onset: - oral: 30 mins to 96 hrs - rectal 5 - 30 mins

Meloxicam

BN: Mobic NSAID with increased COX-2 selectivity

Isosorbide Mononitrate

BN: Monoket, Imdur MOA: Long acting nitrate, reduces myocardial O2 demand, vasodilation of veins more than arteries CI: DO NOT USE with PDE-5 inhibitors Warning: hypotension, HA, tachyphylaxis ADE: HA, flushing, syncope Isosorbide dinitrate in combo with hydralazine is preferred formulation for systolic HF

Naloxegol

BN: Movantik Peripherally-acting Mu opioid receptor antagonist (PAMORA) for constipation

Dronedarone

BN: Multaq MOA: class III antiarrhythmic (blocks K channels) BBW: increased risk of death, stroke and HF in patients with NYHA Class IV or permanent AFIB CI: concurrent use of strong 3A4 inhibitors and QT-prolonging drugs Warning: hepatic failure, pulm disease, increased SCr, ADE: increased QT

Busulfan

BN: Myleran, Bussulfex MOA: alkylating agent, Cell Cycle Independent Drug, cross links DNA strands and inhibits protein synthesis. BBW: myelosuppression, ADE: PULM TOXICITY, moderate-high emetic potential, alopecia, secondary malignancies

Chlorthalidone

BN: N/A MOA: thiazide diuretic inhibits sodium reabsorption in the distal convoluted tubule, causing increased excretion of Na, Cl, water and K. CI: hypersensitivity to sulfonamide-derived drugs ADE: decreases electrolytes (K, Mg, Na). Can increase Ca, UA, LDL, TG, BG. Photosensitivity Monitor: electrolytes and renal function, BP, fluid status Thiazides are not effective when CrCl < 30 Take early and avoid night doses Chlorthalidone is the only thiazide available IV DDI: NSAIDs can cause water and Na retention and decrease the effectiveness of thiazide. Thiazides decrease lithium renal clearance and increase risk of lithium toxicity.

Naloxone

BN: Narcan opioid antagonists (nasal spray or injection) can cause acute opioid withdrawal symptoms

Pegfilgrastim

BN: Neulasta (once per chemo cycle) MOA: growth colony stimulating factor (CSF), stimulate the production of WBCs in the bone marrow Pts with >/= 20% of developing chemotherapy induced febrile neutropenia should receive a CSF ADE: bone pain, injection site rxn

Filgrastim

BN: Neupogen QDAY MOA: growth colony stimulating factor (CSF), stimulate the production of WBCs in the bone marrow Pts with >/= 20% of developing chemotherapy induced febrile neutropenia should receive a CSF ADE: bone pain, injection site rxn

Esomeprazole

BN: Nexium PPI: GERD = 8 week treatment course and then evaluate need for maintenance therapy. Warnings: - C.diff, hypomagnesia, vitamin B12 deficiency associated with use > 2 years, osteoporosis bone fracture with high does > 1 year use Do not use while on clopidogrel Available IV (Pantoprazole too) Can open capsule and mix with apple sauce Inhibits: 2C19

Drugs Commonly Associated with Allergic Reactions

Beta-lactams - if true allergy avoid all beta-lactams (penicillin's, cephalosporins, and carbapenems. Can use Aztreonam Sulfa drugs - sulfamethoxazole, sulfasalazine, sulfadiazine, sulfisoxazole, thiazide diuretics, loop diuretics, sulfonylureas, acetazolamide, zonisamide, celecoxib, darunavir - sulfite or sulfate allergies do not cross react Opioids - histamine release is common but true allergy is not - the common drugs in the same chemical class that cross-react with each other have "cod" or "morph" (buprenorphine has "norph" instead" Heparin - HIT Biologics NSAIDs Contrast Media Peanuts and soy - avoid clevidipine (Cleviprex), propofol (diprivan), progesterone Eggs - avoid clevidipine (cleviprex), propofol (diprivan), yellow fever vaccine

Hydrophilic Antibiotics

Beta-lactams (wall), Aminoglycosides (protein), Glycopeptides, Daptomycin, Polymyixns - small VD = poor tissue penetration - renal elimination = nephrotoxicity or accumulation - low intracellular concentrations = not active vs atypical pathogens - increased clearance and/or distribution in sepsis - poor-moderate bioavailability = not used PO or IV:PO ratio is not 1:1

Amiodarone

BN: Nexterone, Pacerone (tab, injection) Use: class III antiarrhythmic, used for many arrhythmias AFIB, preferred for HF MOA: k-channel blocker, BB, alpha blocker, CCB, and Na blocker BBW: pulmonary toxicity, hepatoxicity, for life threatening arrhythmias only, loading dose must be done in hospital CI: iodine hypersensitivity Warnings: hyper and hypo thyroidism, optic neuropathy (visual impairment), photosensitivity (slate-blue skin discoloration), neurotoxicity (peripheral neuropathy, severe skin rxns (SJS/TENS) ADE: hypotension, bradycardia, corneal microdeposits, photosensitivity Monitoring: ECG, HR, electrolytes LFTs: every 6 months, thyroid function tests every 3-6 months, CXR at least annually, regular eye exams Notes: Non-PVC container needed for infusion > 2 hrs Teratogenic

Niacin

BN: Niaspan MOA: for cholesterol: decreases the rate of hepatic synthesis of VLDL (decreases TG and LDL). Titrate slowly and take with meals CI: active liver disease, active PUD or arterial bleeding Warnings: RHABDO when niacin doses >/= 1 g/day combined with statins, hepatotoxicity, increased BG and uric acid ADE: FLUSHING, pruritus, VD, increased BG, hyperuricemia (gout) Monitor LFTs Lipid effects: decreases TG: ~ 20 - 50% increases HDL: ~ 15 - 35% decreases LDL: ~ 5 - 25% Take 4 - 6 hours before bile acid sequestrants

Nicotine Patch

BN: Nicoderm CQ Initial dose: - if > 10 cigs/day 21 mg patch x 6 wks - if </= 10 cigs/day 14 mg patch x 6 wks Warnings: avoid in immediate post MI, life threatening arrhythmias, severe or worsening angina and pregnancy ADE: vivid dreams, HA, dizziness, insomnia, nervousness FDA prohibits the sale of nicotine products < 18 yo Combo therapy with patch and gum is most effective Remove patch before MRI

Nicotine Polacrilex gum / Lozenges

BN: Nicorette / Nicorette mini Wks 1 - 6: 1 piece Q1 - 2 Wks 7 - 9: 1 piece Q2 - 4 Wks 10 - 12: 1 piece Q4 - 8 Minimum: 9 pieces/day 1st 6 weeks Max: 24/day gum and 20/day lozenges ADE: HA, dizziness, insomnia, nervousness Combo therapy with patch and gum is most effective FDA prohibits the sale of nicotine products < 18 yo

Nitroglycerin ointment

BN: Nitro-BID long acting nitrate for angina

Nitroglycerin

BN: Nitrostat (SL tab), NitroMist (translingual spray) Dose: 0.4 mg MOA: short acting nitrate, reduces myocardial O2 demand, vasodilation of veins more than arteries CI: DO NOT USE with PDE-5 inhibitors Recommended in all patients with angina/ischemic heart disease for immediate relief Warning: hypotension, HA, tachyphylaxis ADE: HA, flushing, syncope Keep tablets in amber glass bottle; discard after 6 months from opening Take one dose at first sign of chest pain and call 911 in pain persists, continue to take 2 additional doses at 5 minute intervals, do not take more than 3 doses within 15 mins

Hydrocodone

BN: Norco (IR), (ER: Zohydro, Hysingla) opioid

Amlodipine

BN: Norvasc MOA: dihydropyridine CCB, inhibits Ca ions from entering vascular smooth muscle and myocardial cells and this causes peripheral arterial vasodilation Warning: hypotension ADE: generally well tolerated, peripheral edema, HA, flushing, palpations, reflex tachycardia, gingival hyperplasia DDI: major substrate for 3A4, do not use with grapefruit

Tapentadol

BN: Nucynta - centrally acting analgesics (mu opioid receptor agonists and inhibitor of norepinephrine reuptake) - can increase seizure risk and serotonin syndrome risk - Do not use with concurrent MAOI or with 14 days of use.

Biphasic and Triphasic Combination Oral Contraceptives

BN: Ortho Tri-Cyclen Lo, Tri-Sprintec Hormones are delivered in phases usually ethinyl estradiol (EE), and progestin (norethindrone, levonorgestrel, drospirenone) ADE: N, breast tenderness/fullness, bloating, weight gain, elevated BP - severe: thrombosis, stroke, DVT, MI Progestin ADE: breast tenderness, HA, fatigue, changes in mood. if late cycle breakthrough bleeding occurs an increase progestin dose may be needed BBW: do not use in women > 35 y/o who smoke due to risk of serious CV events

Calcium Carbonate

BN: Os-Cal, Tums Calcium supplement (40% elemental calcium) for osteoporosis or osteopenia ADE: hypercalcemia, CONSTIPATION, nausea Monitor: Ca, PO4, PTH Take with food and do not use PPI's

Ospemifene

BN: Osphena MOA: estrogen agonists/antagonists indicated for dyspareunia (painful intercourse) BBW: endometrial cancer (if estrogen used without progestin in women with uterus), dementia (women >/=65), stroke, breast cancer Should not be used in women with severe hepatic impairment

Voxelotor

BN: Oxbryta MOA: for sickle cell disease, inhibits hemoglobin S (HbS) polymerization, which is the cause of sickle cell. ADE: HA, fatigue, ab pain

Nortriptyline

BN: Pamelor MOA: TCA, primarily inhibit NE and 5-HT reuptake. They also block ACh and histamine receptors. CI: MAOI's, linezolid, IV methylene blue, glaucoma and urinary retention ADE: QT prolongation with OD, suicidal ideation, orthostasis - anticholinergic: dry mouth,, blurred vision, urinary retention, constipation, vivid dreams, weight gain, falls Secondary amine: more selective for NE

Brisdelle

BN: Paroxetine MOA: SSRI for moderate to severe vasomotor symptoms postmenopause DDI: CYP450 2D6 inhibitor so do not use with tamoxifen or warfarin BBW: increases suicide risk Lower dose for vasomotor symptoms then with depression

Paroxetine

BN: Paxil MOA: SSRI Most sedating, take in PM BBW: possible increase in suicidal thoughts or actions in some children, teenagers or young adults within the first few months of treatment CI: MAOI's, linezolid, IV methylene blue, thioridazine Warning: SIADH/hyponatremia, fall risk, bleeding ADE: sexual: decreased libido, ejaculation difficulties, ED; somnolence, insomnia, nausea, dry mouth, diaphoresis, weakness, tremor, dizziness, HA

Famotidine

BN: Pepcid H2R Antagonist: Heartburn/GERD Warning: Confusion, ECG changes with renal dysfunction

Bismuth Subsalicylate

BN: Pepto-Bismol Antidiarrheal CI: salicylate allergy, GI ulcer, taking other salicylates, bleeding problems, black/bloody stool Warning: can cause Reye's syndrome in children recovering from flu. ADE: black tongue/stool, salicylate toxicity (tinnitus, metabolic acidosis, nausea

Promethazine

BN: Phenergan Use: antiemetic in CA in low emetic risk MOA: dopamine receptor antagonist in the CNS and chemoreceptor zone BBW: do not use in children <2 yo (resp depression), do not give IV or SC (serious tissue injury) Warning: Parkinson disease may be exacerbated ADE: sedation, lethargy, acute EPS, decreased seizure threshold, NMS, anticholinergic effects

Hydroxychloroquine

BN: Plaquenil USE: DMARD for RA Warning: irreversible retinopathy ADE: NVD, ab pain, rash, ect Monitoring: EYE EXAM and muscle strength at baseline and every 3 months

Clopidogrel

BN: Plavix (75 mg QDay) MOA: antiplatelet prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation. BBW: prodrug and effectiveness depends on the conversion to active metabolite mainly by 2C19. CI: active serious bleeding Warnings: bleeding risk, stop 5 days prior to surgery ADE: generally well tolerated unless bleeding occurs Used in stable ischemic heart disease DDI: avoid with 2C19 inhibitors (omeprazole and esomeprazole)

Dabigatran

BN: Pradaxa MOA: directly inhibit thrombin (factor IIa) 150 mg BID PO, if missed dose take ASAP unless w/in 6 hours of next dose BBW: patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal procedure are at risk for hematomas and subsequent paralysis CI: pts with mechanical heart valves ADE: DYSPEPSIA, gastritis like symptoms, bleeding No monitoring required Antidote: idarucizumab (Praxbind) Protect from moisture, dispense in original container and discard after 4 months of opening

Alirocumab

BN: Praluent MOA: Proprotein convertase subtilisin kexin type 9 inhibitor (PCSK9 i) block the ability of PCSK9 to bind to LDL receptor reducing LDL Warning: allergic reactions ADE: injection site reactions Lipid Effects: decreases LDL: ~ 60% decreases non-HDL: ~ 35% decreases apoB: ~ 50% decreases TC: ~ 36%

Pravastatin

BN: Pravachol MOA: inhibits HMG-CoA reductase which prevents the conversion HMG-CoA to mevalonate. CI: do not use in pregnancy or breastfeeding, with liver disease Warnings: muscle damage, increased CPK, acute renal failure ADE: generally well tolerated, myalgias/myopathy Lipid effects: decreases LDL ~ 20 - 55% increases HDL ~ 5 - 15% decreases TG ~ 10 - 30%

Conjugated Equine Estrogens

BN: Premarin (vag cream) Use: menopausal vasomotor symptoms, vaginal atrophy, and osteoporosis prevention. These use estradiol while contraception uses ethinyl estradiol Local products may reduce systemic ADE BBW: endometrial cancer (if estrogen used without progestin in women with uterus), dementia (women >/=65), stroke, breast cancer CI: estrogen containing products: breast cancer, undiagnosed uterine bleeding, active VTE, pregnancy Warnings: increase risk of breast cancer ADE: edema, HTN, HA, weight gain, depression, ab pain, N

Lansoprazole

BN: Prevacid PPI: GERD = 8 week treatment course and then evaluate need for maintenance therapy. Warnings: - C.diff, hypomagnesia, vitamin B12 deficiency associated with use > 2 years, osteoporosis bone fracture with high does > 1 year use Can open capsule and mix with apple sauce Inhibits: 2C19

Omeprazole

BN: Prilosec PPI: GERD = 8 week treatment course and then evaluate need for maintenance therapy. Warnings: - C.diff, hypomagnesia, vitamin B12 deficiency associated with use > 2 years, osteoporosis bone fracture with high does > 1 year use Do not use while on clopidogrel Can open capsule and mix with apple sauce Inhibits: 2C19

Lisinopril

BN: Prinivil, Zestril MOA: ACE inhibitor, blocks the conversion of angiotensin 1 to angiotensin 2, resulting in decreased vasoconstriction and decreased aldosterone secretion. They block the degradation of bradykinin which is thought to contribute to the vasodilatory effects (and side effects of dry hacking cough and angioedema) DECREASE MORTALITY AND MORBIDITY IN HF BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected CI: hx of angioedema, within 36 hrs use of sacubitril/valsartan (Entresto) Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal stenosis (avoid use) ADE: generally well tolerated, can cause cough, hyperkalemia, increase SCr, hypotension

Desvenlafaxine

BN: Pristiq MOA: SNRI Uses: depression, generalized anxiety disorder, panic disorder, social anxiety disorder CI: MAOIs, linezolid, IV methylene blue Warnings: SIADH/hyponatremia, fall risk, bleeding ADE: sexual: decreased libido, ejaculation difficulties, ED; somnolence, insomnia, nausea, dry mouth, diaphoresis, weakness, tremor, dizziness, HA NE: increased HR, dilated pupils, dry mouth, excessive sweating, and constipation, increase BP

Albuterol

BN: ProAir, Proventil (SABA) MOA: beta-2 agonists, relaxation of bronchial smooth muscle leading to bronchodilation Warning: caution in CVD, glaucoma, hyperthyroidism, seizures, diabetes ADE: nervousness, tremors, tachycardia, tremors, palpitations, cough, hyperglycemia, decrease K For exercise induced bronchospasm: 2 puffs 5 minutes prior to exercise

Denosumab

BN: Prolia MOA: binds RANKL and blocks its interaction with RANK to prevent osteoclast formation; used in tx of osteoporosis when there is high risk fractures. CI: hypocalcemia, pregnancy Warning: ONJ (osteonecrosis of jaw), atypical femur fractures, hypocalcemia ADE: HTH, fatigue, edema, dyspepsia, HA, NVD, decrease PO4

Pantoprazole

BN: Protonix PPI: GERD = 8 week treatment course and then evaluate need for maintenance therapy. Warnings: - C.diff, hypomagnesia, vitamin B12 deficiency associated with use > 2 years, osteoporosis bone fracture with high does > 1 year use Available IV (Esomeprazole also) Inhibits: 2C19

Medroxyprogesterone

BN: Provera Use: menopausal vasomotor symptoms, vaginal atrophy, and osteoporosis prevention. These use estradiol while contraception uses ethinyl estradiol

Fluoxetine

BN: Prozac MOA: SSRI Most activating: take in AM No taper required when DCing (long t1/2, self tapers) BBW: possible increase in suicidal thoughts or actions in some children, teenagers or young adults within the first few months of treatment CI: MAOI's, linezolid, IV methylene blue, thioridazine Warning: SIADH/hyponatremia, fall risk, bleeding ADE: sexual: decreased libido, ejaculation difficulties, ED; somnolence, insomnia, nausea, dry mouth, diaphoresis, weakness, tremor, dizziness, HA

Budesonide Inhaled

BN: Pulmicort MOA: inhibits inflammatory process, block late phase reaction to allergens, reduce airway hyperresponsiveness. CI: acute episode of asthma Warnings: high doses for prolonged periods can cause adrenal suppression, increase risk of fractures, growth retardation, and immunosuppression ADE: dysphonia (difficulty speaking), oral candidiasis (thrush), cough, HA, URIs Rinse month and spit after each use to prevent thrush

Mercaptopurine

BN: Purixan - thiopurine for UC and CD - take on empty stomach - ADE: NVD, rash, increased LFTs

Beclomethasone Inhaled

BN: QVAR RediHaler (ICS) MOA: inhibits inflammatory process, block late phase reaction to allergens, reduce airway hyperresponsiveness. CI: acute episode of asthma Warnings: high doses for prolonged periods can cause adrenal suppression, increase risk of fractures, growth retardation, and immunosuppression ADE: dysphonia (difficulty speaking), oral candidiasis (thrush), cough, HA, URIs Rinse month and spit after each use to prevent thrush Breath activated and do not use with spacer, do not shake

Ribavirin

BN: Rebetol MOA: RBV is an oral antiviral that inhibits replication of RNA and DNA viruses. Can be used for HCV in combo, never alone BBW: significant teratogenic effects, not effective as monotherapy for HCV, hemolytic anemia CI: pregnancy ADE: hemolytic anemia

Zoledronic acid

BN: Reclast (only IV) Zometa: for hypercalcemia of malignancy MOA: bisphosphonate for osteoporosis: inhibits osteoclast activity and bone reabsorption. Uses: osteoporosis prevention or tx (1st line), Paget's disease, glucocorticoid-induced osteoporosis (in pts taking >/= 7.5 mg daily of prednisone or equivalent) CI: hypocalcemia, inability to stand or sit upright for at least 30 minutes Warning: ONJ (necrotic jaw), atypical femur fractures, esophagitis/erosions, hypocalcemia Renal impairment: CrCl < 35 do not use ADE: Dyspepsia, dysphagia, heartburn, NV, hypocalcemia, (extra from others: edema, hypotension, dehydration, decreases PO4, K and Mg IV: acute phase reactions (flu like symptoms)

Metoclopramide

BN: Reglan Use: antiemetic in CA MOA: dopamine receptor antagonist in the CNS and chemoreceptor zone BBW: TD that can be irreversible Warning: Parkinson disease may be exacerbated ADE: sedation, lethargy, acute EPS, decreased seizure threshold, NMS

Metoclopromide

BN: Reglan dopamine antagonist: helps with N/V, accelerated gastric emptying BBW: can cause tardive dyskinesia CI: GI obstruction, perforation or hemorrhage, hx of seizures. Patients receiving medication for Parkinson's

Methylnaltraxone

BN: Relistor Peripherally-acting Mu opioid receptor antagonist (PAMORA) for constipation

Mirtazapine

BN: Remeron Commonly used in oncology and skilled nursing to help with sleep and increase appetite (take at night) MOA: tetracyclic antidepressant: has central presynaptic alpha-2 adrenergic antagonist effects, which results in increased release of NE and 5-HT Warnings: anticholinergic effects, QT prolongation, blood dyscrasias, CNS depression ADE: sedation, increased appetite, weight gain, dry mouth, dizziness

Infliximab

BN: Remicade MOA: Anti-TNF biologic DMARD BBW: serious infections, malignancies CI: active systemic infection Warnings: demyelinating disease, hep B reactivation, HF, hepatotoxicity, lupus-like syndrome DO NOT use other biologic DMARDs or live vaccines MXT is 1st line and these are add ons

Abciximab

BN: ReoPro MOA: antiplatelet, Glycoprotein IIb/IIIa Receptor Antagonists CI: thrombocytopenia (platelets <100,000). active internal bleeding, severe uncontrolled HTN ADE: bleeding, thrombocytopenia must filter

Temazepam

BN: Restoril MOA: enhance GABA, an inhibitory neurotransmitter, which caused CNS depression resulting in anxiolytic, anticonvulsant, sedative and/or muscle relaxant properties BBW: use with opioids can result in sedation, resp depression, coma and death. CI: acute narrow-angled glaucoma, sleep apnea, resp depression Warning: dependence and tolerance, do not DC abruptly. CNS depression, crosses placenta ADE: somnolence dizziness, ataxia C-IV Antidote: Flumazenil

Risperidone

BN: Risperdal MOA: second generation antipsychotic (SGA), blocks dopamine (D2) and serotonin (5-HT2A) receptors. BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics ADE: increase prolactin, sexual dysfunction, galactorrhea, irregular periods, EPS, metabolic syndrome (increased weight, BG, lipids) Can be used alone or in combo with mood stabilizers for bipolar depression for acute mania

Methylphenidate

BN: Ritalin (IR, LA ER), Concerta (ER), Daytrana (patch) MOA: stimulant for ADHD (1st line), blocks reuptake or NE and dopamine. Stimulants do not need to be tapered for DCing BBW: high potential for abuse and dependence CI: within 14 days of a MAOI, heart issues Warnings: increase HR and BP, loss of appetite, risk of serotonin syndrome ADE: insomnia, decreased appetite, HA, irritability Daytrana: apply 2 hours before desired effect, remove after 9 hours and alternate hips daily

Rituximab

BN: Rituxan MOA: DMARD, depletes CD20 B cells Premedicate with a steroid, APAP, and an antihistamine BBW: serious and fatal infusion rxns Warnings: do not give with other biologic DMARDs or live vaccines ADE: infusion related rxns, URTIs, UTIs, NVD

Rituximab

BN: Rituxan MOA: leukocyte cluster differentiation (CD) Antigens (CD20, CD30, CD19, CD3, CD38) inhibitor premedicate with diphenhydramine, acetaminophen, steroid BBW: hepatitis B reactivation, PML, serious skin rxns ADE: rash, peripheral edema, HTN, tumor lysis syndrome

Methocarbomol

BN: Robaxin Antispasmodic that exerts is effect by sedation

Calcitriol

BN: Rocaltrol (active form of vitamin D3) USES: tx for secondary hyperparathyroidism, vitamin D deficiency MOA: vitamin D analog used for later stages of CKD or ESRD, to increase intestinal absorption of Ca, which provides negative feedback to the parathyroid gland CI: hypercalcemia, vitamin D toxicity ADE: hypercalcemia

Oxycodone

BN: Roxicodone, Oxycontin, Xtampza Opioid

Propafenone

BN: Rythmol SR (NOT USED OFTEN) MOA: class IC antiarrhythmic (blocks Na channels) CI: structural heart disease including (HF and MI) ADE: taste disturbances

Sodium Polystyrene Sulfonate

BN: SPS, Kayexalate MOA: used for tx of hyperkalemia, binds K in GI tract Warning: can bind other oral medications ADE: NVDC

Granisetron

BN: Sancuso (PO, IV, SC, Patch apply 24-48 hrs before chemo) Use: antiemetic, 1 of CINV combo med MOA: 5HT-3 (serotonin) receptor antagonist CI: do not use with apomorphine due to severe hypotension and loss of consciousness Warnings: dose dependent increase in QT interval (torsades de pointes). Serotonin syndrome when used in combo with other serotonergic agents ADE: HA, constipation

Octreotide

BN: Sandostatin MOA: selective vasoconstricting agent for splanchnic vessels, used for varices Uses: Varices, especially esophageal varices caused by liver disease/portal HTN ADE: bradycardia, cholelithiasis, biliary sludge Non-selective BB should be added after bleeding resolution for secondary prevention

Cinacalcet

BN: Sensipar MOA: used ONLY IN DIALYSIS PATIENTS for vitamin D deficiency and secondary hyperparathyroidism, increases sensitivity of Ca-sensing receptors on the parathyroid gland, which causes decreased PTH, decreased Ca and decreased PO4 CI/ADE: hypocalcemia

Salmeterol

BN: Serevent Diskus (LABA) MOA: beta-2 agonists, relaxation of bronchial smooth muscle leading to bronchodilation BBW: increased risk of asthma related deaths: should only be used in patients who are also currently receiving ICS Warning: caution in CVD, glaucoma, hyperthyroidism, seizures, diabetes ADE: nervousness, tremors, tachycardia, tremors, palpitations, cough, hyperglycemia, decrease K

Quetiapine

BN: Seroquel Use: second generation antipsychotic that can be used in treatment resistant depression too. MOA: second generation antipsychotic (SGA), blocks dopamine (D2) and serotonin (5-HT2A) receptors. BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics ADE: metabolic issues, sedation, orthostasis, weight gain, increased lipids, increased glucose Low EPS risk - often used for psychosis in Parkinson disease

Sevelamer

BN: Sevelamer carbonate (Renvela), Sevelamer hydrochloride (Renagel) non-ca and non-al phosphate binder that is not systemically absorbed Take with meals TID and skip if meal is skipped CI: bowel obstruction ADE: NVD (all >20%) Lower total cholesterol and LDL by 15-30%

Golimumab

BN: Simponi MOA: Anti-TNF biologic DMARD BBW: serious infections, malignancies CI: active systemic infection Warnings: demyelinating disease, hep B reactivation, HF, hepatotoxicity, lupus-like syndrome DO NOT use other biologic DMARDs or live vaccines MXT is 1st line and these are add ons

Montelukast

BN: Singulair (for asthma) MOA: Leukotriene receptor antagonist inhibit leukotriene mediators of airway inflammation (LTD4) Dose: 10 mg PO evening, 6-14 yo 5 mg, 1-5 4 mg BBW: neuropsychiatric events ADE: HA, dizziness, ab pain, increased LFTs, URIs

Ferrous sulfated, dried

BN: Slow Fe, Slow Iron Dose: 160 mg (50 mg elemental iron) PO QD-TID For iron deficiency anemia and normocytic anemia BBW: accidental OD of iron containing products is the leading cause of fatality in children. CI: hemolytic anemia, hemochromatosis ADE: constipation (dose related), dark and tarry stools Docusate (stool softener) often recommended for constipation Antidote for OD: deferoxamine (Desferal)

Tamoxifen

BN: Soltamox MOA: SERM, estrogen antagonist in breast tissue. CDK4/6 inhibitor DDI: do not use with CYP2D6 inhibitors bc tamoxifen is a prodrug metabolized by 2D6 BBW: increased risk of uterine or endometrial cancer, increased risk of thromboembolic events CI: do not use with warfarin, hx of DVT/PE ADE: hot flashes/night sweats, vaginal bleeding/spotting, vaginal discharge/dryness/pruritus, decreases libido, eye damage, decreased bone density-supplement calcium/vitamin D venlafaxine for hot flashes and night sweats Teratogenic: use contraception 1st line treatment for PREMENOPAUSAL women with hormone-sensitive (ER+ or PR+ or ER+/PR+) breast cancer

Hydrocortisone

BN: Solu-Cortef MOA: glucocorticoid (systemic steroid) Take in morning if QDAY with FOOD CI: live vaccines, serious systemic infections Warning: adrenal suppression: must taper slowly Short-term ADE: increased appetite/weight gain, emotional instability, insomnia, fluid retention, increased intraocular pressure, HTN Long-term ADE: cushing's syndrome

Carisoprodol

BN: Soma Antispasmodic that exerts is effect by sedation Poor 2C19 inhibitors will have and increase in concentration

Tiotropium

BN: Spiriva (Long acting anticholinergic for COPD) MOA: cause bronchodilation by blocking the constricting action of the acetylcholine at M3 muscarinic receptors in the bronchial smooth muscle. Warning: use caution in pts with narrow angle glaucoma, MG, urinary retention, BPH, and bladder neck obstruction ADE: dry mouth, URTI's

Atomaxetine

BN: Strattera MOA: non-stimulant for ADHD, 2nd line after trials of stimulants have failed but can be 1st line if abuse potential. SNRI BBW: risk of suicidal ideation CI: MAOI use within 14 days ADE: decreased appetite, insomnia, somnolence, dry mouth, HTN, tachycardia

Buprenorphine + Naloxone

BN: Suboxone Naloxone: opioid antagonists Buprenorphine: partial mu agonists

Budesonide + Formoterol

BN: Symbicort (ICS + LABA)

Tenecteplase

BN: TNKase MOA: fibrinolytic, cause fibrinolysis (clot breakdown) by binding fibrin and converting plasminogen to plasmin. Used for STEMI only. PCI in preferred if it can be performed within 90 minutes or within 120 minutes of first medical contact. If not possible than fibrinolytic is recommended and should be given within 30 minutes of hospital arrival. CI: ACTIVE INTERNAL BLEEDING, HISTORY OF RECENT STROKE, any prior intracranial hemorrhage (ICH), recent intracranial or intraspinal surgery or trauma in the last 2-3 months, aneurysm, SEVERE UNCONTROLLED HTN ADE: BLEEDING (including ICH) Monitoring: Hgb, Hct, s/sx of bleeding

Cimetidine

BN: Tagamet H2R Antagonist: Heartburn/GERD Warning: Confusion ADE: gynecomastia, impotence (both with higher doses) AVOID due to DDI and side effects

Paclitaxel

BN: Taxol MOA: inhibits microtubules during M phase Hypersensitivity rxn: premedicate with diphenhydramine, steroid, H2RA BBW: severe hypersensitivity rxns, myelosuppression ADE: peripheral sensory neuropathy, alopecia use non-PVC bag and tubing and filter

Docetaxel

BN: Taxotere MOA: inhibits microtubules during M phase Hypersensitivity rxn: premedicate with diphenhydramine, steroid, H2RA BBW: severe hypersensitivity rxns, myelosuppression ADE: peripheral sensory neuropathy, alopecia use non-PVC bag and tubing

Aliskiren

BN: Tekturna MOA: directly inhibits renin, which is responsible for the conversion of angiotensinogen to angiotensin 1. A decrease in angiotensin 1 will decrease in formation to angiotensin 2. CI: do not use with ACEI or ARBs in patients with diabetes BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected ADE: generally well tolerated, can cause cough (less than ACEI), hyperkalemia, increase SCr, hypotension, angioedema (less than ACEI)

Atenolol

BN: Tenormin MOA: beta-1 selective blocker, decreases HR and myocardial contractility BBW: do not DC abruptly, taper over 1-2 weeks CI: severe bradycardia, 2nd or 3rd degree heart block Warnings: caution in diabetes, can increase or decrease BG and mask hypoglycemic symptoms. ADE: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud's exacerbation

Dofetilide

BN: Tikosyn MOA: class III antiarrhythmic, blocks K channels BBW: must be initiated in a setting with continuous ECG monitoring Antiarrhythmic DOC in HF

Metoprolol Succinate

BN: Toprol XL (tab QDay, sprinkle) MOA: beta-1 selective blocker, decreases HR and myocardial contractility BBW: do not DC abruptly, taper over 1-2 weeks CI: severe bradycardia, 2nd or 3rd degree heart block Warnings: caution in diabetes, can increase or decrease BG and mask hypoglycemic symptoms. ADE: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud's exacerbation When switching from tartrate to succinate the same dose of metoprolol should be used 1 OF 3 BB APPROVE FOR CHRONIC HF (decreases morbidity and mortality)

Ketorolac

BN: Toradol NSAID BBW: max combined duration (IV/IM/PO) is 5 days.

Linagliptin

BN: Tradjenta - MOA: DPP-4i increases incretin-> less glucagon. Lowers A1C 1% - Do not use with GLP-1 RA because similar MOA - Does not need renal adjustment (other DDP-4is do) - Warning: pancreatitis, severe arthralgia, acute renal failure

Scopolamine

BN: Transderm Scop - anticholinergic for motion sickness - apply one patch behind the ear at least 4 hours before effects needed, may use a new patch every 3 days PRN - CI: hypersensitivity to Belladonna alkaloids, angle closure glaucoma - Remove patch before MRI, contains metal

Methotrexate

BN: Trexall MOA: folate antimetabolite, blocks purine and pyrimidine biosynthesis during S phase High dose methotrexate requires Levoleucovorin BBW: myelosuppression, renal damage, hepatotoxicity, GI toxicity, teratogenicity ADE: nephrotoxicity, hepatotoxicity, nausea, MUCOSITIS

Methotrexate (for RA)

BN: Trexall MOA: folate antimetabolite, blocks purine and pyrimidine biosynthesis during S phase, inhibits dihydrofolate reductase, inhibiting folate. LOW WEEKLY doses for RA (never daily) High dose methotrexate requires Levoleucovorin (cancer) BBW: myelosuppression, renal damage, hepatotoxicity, GI toxicity, mucositis/stomatitis, teratogenicity ADE: nephrotoxicity, hepatotoxicity, nausea, MUCOSITIS Monitoring: CBCs, LFTs, chest X-ray, hep B and C serology Can give folate to decrease hematological, GI and hepatic ADEs DDI: do not take with alcohol, NSAIDs decrease elimination

Calcium Carbonate

BN: Tums (+ magnesium: Mylanta supreme) (+ simethicone: Maalox Advanced) Heartburn/GERD - relief in minutes but does not last long - use if symptoms < 2 times a week - Can cause constipation - Ca products preferred in pregnancy

Acetaminophen

BN: Tylenol Can cause hepatotoxicity Max dose <4000 mg/day N-acetylcysteine (NAC) antidote for overdose

Acetaminophen + Codeine

BN: Tylenol #2, 3, 4

Abaloparatide

BN: Tymlos (injection) MOA: analog of parathyroid hormone which stimulates osteoblast activity and increases bone formation (for osteoporosis when there is a very high risk of fracture BBW: osteosarcoma (bone cancer) Warnings: hypercalcemia, orthostatic hypotension ADE: arthralgias, leg cramps, N, orthostasis/dizziness Cumulative treatment duration: 2 years or less due to safety issues

Febuxostat

BN: Uloric Xanthine oxidase inhibitor for chronic gout limited to those who cannot take allopurinol or those whom allopurinol does not work for. Warnings: hepatotoxicity, increased chance of thromboembolic events, hypersensitivity and serious skin rxns.

Acetaminophen + Tramadol

BN: Ultracet

Tramadol

BN: Ultram - centrally acting analgesics (mu opioid receptor agonists and inhibitor of norepinephrine and serotonin reuptake) seizure risk (avoid in patients with history of seizures, head trauma), risk of serotonin syndrome with other serotonergic drugs or inhibitors of 2D6 or 3A4. - Do not use with concurrent MAOI or with 14 days of use.

Diazepam

BN: Valium MOA: enhance GABA, an inhibitory neurotransmitter, which caused CNS depression resulting in anxiolytic, anticonvulsant, sedative and/or muscle relaxant properties BBW: use with opioids can result in sedation, resp depression, coma and death. CI: SEVERE LIVER DISEAES (also for clonazepam), acute narrow-angled glaucoma, sleep apnea, resp depression Warning: dependence and tolerance, do not DC abruptly. CNS depression, crosses placenta ADE: somnolence dizziness, ataxia C-IV Antidote: Flumazenil Commonly used for alcohol withdrawal syndrome (Lorazepam also)

Icosapent ethyl

BN: Vascepa MOA: unknown but indicated as adjunct to diet when TG >/= 500 (EPA and icosapent ethyl, NO DHA) Warning: caution in patients with fish/shellfish allergies ADE: eructation (burping), dyspepsia, taste perversions, arthalgias Lipid Effects: decreased TG: ~ 45% increases HDL ~ 9% can increase LDL up to 44% (only lovaza, not seen with Vascepa)

Enalapril

BN: Vasotec MOA: block the conversion of angiotensin I to angiotensin II resulting in decreased vasoconstriction and decreased aldosterone secretion. Decrease cardiac remodeling and improve LV function and DECREASE MORTALITY AND MORBIDITY in HF BBW: injury and death to fetus, stop as soon as pregnancy detected. CI: hx of angioedema, do not use within 36 hours of sucubitril/valsartan (Entresto) Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (avoid use) ADE: generally well tolerated, cough, hyperkalemia, increase SCr, hypotension, dizziness Monitoring: BP, K, renal function, s/sx of HF, angioedema

Enalaprilat

BN: Vasotec IV (Enalaprilat) MOA: ACE inhibitor, blocks the conversion of angiotensin 1 to angiotensin 2, resulting in decreased vasoconstriction and decreased aldosterone secretion. They block the degradation of bradykinin which is thought to contribute to the vasodilatory effects (and side effects of dry hacking cough and angioedema) BBW: can cause injury and death to the developing fetus, DC as soon as pregnancy is detected CI: hx of angioedema, within 36 hrs use of sacubitril/valsartan (Entresto) Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal stenosis (avoid use) ADE: generally well tolerated, can cause cough, hyperkalemia, increase SCr, hypotension

Tenofovir Alafenamide (TAF)

BN: Vemlidy MOA: nucleoside/tide reverse transcriptase inhibitor (NRTI), inhibit HBV replication by inhibiting HBV polymerase resulting in DNA chain termination Prior to starting test for HIV BBW: lactic acidosis and severe hepatomegaly with steatosis, exacerbations of HBV can occur with DCing Warnings: renal toxicity, Fanconi syndrome, osteomalacia and decreased bone density ADE: nausea A LOT LESS DECREASE IN RENAL FUCTION AND BONE TOXICITY compared to TDF can be 1st line for HBV

Eluxadoline

BN: Viberzi Peripherally-Acting Mu-Opioid Receptor Agonist for diarrhea CI: patients without a gallbladder, alcoholism or > 3 alcoholic drinks/day, pancreatic disease

Tenofovir Disproxil Fumarate (TDF)

BN: Viread MOA: nucleoside/tide reverse transcriptase inhibitor (NRTI), inhibit HBV replication by inhibiting HBV polymerase resulting in DNA chain termination Prior to starting test for HIV BBW: lactic acidosis and severe hepatomegaly with steatosis, exacerbations of HBV can occur with DCing Warnings: renal toxicity, Fanconi syndrome, osteomalacia and decreased bone density ADE: renal impairment, decreased BMD, NVD can be 1st line for HBV

Diclofenac

BN: Voltaren NSAID with increased COX-2 selectivity - Gel: upper body do not exceed 8 grams/day, lower body do not exceed 16 grams/day.

Lisdexamfetamine

BN: Vyvnase (Capsule and chewable tab) MOA: stimulant for ADHD (1st line), blocks reuptake or NE and dopamine. Stimulants do not need to be tapered for DCing BBW: high potential for abuse and dependence. CI: within 14 days of a MAOI, heart issues Warnings: increase HR and BP, loss of appetite, risk of serotonin syndrome ADE: insomnia, decreased appetite, HA, irritability LOW ABUSE POTENTIAL (if snorted, rush is muted)

Colesevelam

BN: Welchol MOA: bile acid sequestrant bind bile in the intestine forming a complex that is excreted in feces CI: bowel obstruction, TG > 500, hx of hypertriglyeridemia-induced pancreatitis ADE: constipation, ab pain, cramping, bloating, gas, increased TGs Not recommended when TGs are >/= 300 Can be considered for a pregnant pt Take with meal or liquid DDI: can decrease absorption of fat soluble vitamins Lipid effects decreases LDL: ~ 10 - 30% increases HDL: ~ 3 - 5% No change or increase TG: ~ 5% Other bile acid sequestrants Cholestyramine (Prevalite), Colestipol (Colestid)

Bupropion

BN: Wellbutrin (smoking cessation) MOA: blocks neuronal reuptake of dopamine and/or norepinephrine, resulting in reduced cravings and other withdrawal symptoms Start at least 1 week before quit date, and this does not need to be tapered when finishing BBW: increased risk of suicidal thinking and behavior in children, adolescents and young adults CI: seizure disorder, hx of anorexia/bulimia; with MAOI's, linezolid, or IV methylene blue Warnings: serious neuropsychiatric events ADE: dry mouth, insomnia, tremors, weight loss

Bupropion

BN: Wellbutrin SR, XL (Zyban for smoking cessation) MOA: antidepressant; dopamine and NE reuptake inhibitor CI: seizure disorder; hx of anorexia/bulimia, MAOI's, linezolid, IV methylene blue, multiple formulations of bupropion ADE: dry mouth, CNS stimulation (insomnia, restlessness) tremors/seizures, weight loss Sexual dysfunction is rare (no effect on 5-HT)

Alprazolam

BN: Xanax MOA: enhance GABA, an inhibitory neurotransmitter, which caused CNS depression resulting in anxiolytic, anticonvulsant, sedative and/or muscle relaxant properties BBW: use with opioids can result in sedation, resp depression, coma and death. CI: STRONG CYP3A4 INHIBITORS, acute narrow-angled glaucoma, sleep apnea, resp depression Warning: dependence and tolerance, do not DC abruptly. CNS depression, crosses placenta ADE: somnolence dizziness, ataxia C-IV Antidote: Flumazenil

Rivaroxaban

BN: Xarelto MOA: DIRECT factor Xa inhibitors and is only available orally Dose >/= 15 mg must be taken with food Renal dose changes and avoid use CrCl < 15 BBW: patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal procedure are at risk for hematomas and subsequent paralysis CI: active pathological bleeding Warning: not recommended for prosthetic heart valves No monitoring required Antidote: andexanet alfa (Andexxa)

Capecitabine

BN: Xeloda MOA: pyrimidine analog antimetabolite, inhibit pyrimidine synthesis during S phase BBW: significant increase in INR CI: CrCl < 30 ADE: HAND-FOOT SYNDROME, diarrhea, mucositis, cardiotoxicity, photosensitivity

Omalizumab

BN: Xolair MOA: Monoclonal antibody that inhibits IgE binding to the IgE receptor on mast cells and basophils. Indicated for moderate to severe persistent asthma in pts >/= 6 yo with a positive skin test to a perennial areoallergen and inadequate symptom control on ICS (step 5 or 6) Dose: SC every 2 - 4 weeks in controlled setting. BBW: anaphylaxis, so closely monitor Warnings: increased risk of serious CV and cerebrovascular adverse events ADE: injection site rxns, HA, dizziness

Drospirenone Containing Combination Contraceptives

BN: Yasmin 28, Yaz Has estrogen, progesterone and Drospirenone Drospirenone: an unique progestin which is a K sparing diuretic that decreases bloating, PMS symptoms and weight gain; associated with less acne and they have lower androgenic activity ADE: N, breast tenderness/fullness, bloating, weight gain, elevated BP - severe: thrombosis, stroke, DVT, MI Progestin ADE: breast tenderness, HA, fatigue, changes in mood. if late cycle breakthrough bleeding occurs an increase progestin dose may be needed BBW: do not use in women > 35 y/o who smoke due to risk of serious CV events DDI: drugs that increase K (potassium sparing diuretics, ACEI's, ARBs, heparin, Canagliflozin, calcineurin inhibitors

Tizanidine

BN: Zanaflex antispasmodic with analgesic effects CI: with strong 1A2 inhibitors (fluvaxamine, ciprofloxacin)

Ranitidine

BN: Zantac H2R Antagonist: Heartburn/GERD Warning: Confusion, increases in ALT

Ezetimibe

BN: Zetia (+ simvastatin Vytorin) MOA: inhibits absorption of cholesterol in the small intestine (add on tx to statin) Warnings: Avoid use in moderate or severe hepatic impairment, skeletal muscle effects increased when combined with statin ADE: Myalgias, diarrhea, UTIs Lipid effects as monotherapy: decreases LDL ~ 18 - 23% increases HDL ~ 1 - 3% decreases TG ~ 5 - 10% DDI: Do not use with gemfibrozil, concurrent use with bile acid sequestrants decreases ezetimibe so give ezetimibe 2 hours before or 4 hours after

Simvastatin

BN: Zocor (take in evening...zzzz) MOA: inhibits HMG-CoA reductase which prevents the conversion HMG-CoA to mevalonate. CI: do not use in pregnancy or breastfeeding, with liver disease Warnings: muscle damage, increased CPK, acute renal failure ADE: generally well tolerated, myalgias/myopathy Lipid effects: decreases LDL ~ 20 - 55% increases HDL ~ 5 - 15% decreases TG ~ 10 - 30%

Ondansetron

BN: Zofran (IV or PO) Use: antiemetic, 1 of CINV combo med MOA: 5HT-3 (serotonin) receptor antagonist CI: do not use with apomorphine due to severe hypotension and loss of consciousness Warnings: dose dependent increase in QT interval (torsades de pointes). Serotonin syndrome when used in combo with other serotonergic agents ADE: HA, constipation

Goserelin

BN: Zoladex MOA: gonadotropin-releasing hormone agonist reduces testosterone through negative feedback. Initial surge can cause "tumor flare" so give antiandrogen initially for several weeks. USE: prostate CA ADE: decreased bone density (supplement), tumor flare (use antiandrogen: bicalutamide), hot flashes, impotence, gynecomastia, bone pain CI: pregnancy, breastfeeding

Sertraline

BN: Zoloft MOA: SSRI Preferred in pts with cardiac risks BBW: possible increase in suicidal thoughts or actions in some children, teenagers or young adults within the first few months of treatment CI: MAOI's, linezolid, IV methylene blue, thioridazine Warning: SIADH/hyponatremia, fall risk, bleeding ADE: sexual: decreased libido, ejaculation difficulties, ED; somnolence, insomnia, nausea, dry mouth, diaphoresis, weakness, tremor, dizziness, HA

Allopurinol

BN: Zyloprim, Aloprim Xanthine oxidase inhibitor for chronic gout Warnings: hypersensitivity reactions, including severe rash, HLA-B*5801 testing prior to use and do not use if positive, hepatotoxicity

Olanzapine

BN: Zyprexa MOA: second generation antipsychotic (SGA), blocks dopamine (D2) and serotonin (5-HT2A) receptors. Use: antipsychotic and used in antiemetic risk BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics Zyprexa Relprevv (inj): sedation, coma, delirium, need to be monitored for 3 hrs post injection ADE: somnolence, metabolic syndrome (increased weight, BG, TG) Can be used alone or in combo with mood stabilizers for bipolar depression for acute mania

Influenza vaccine

BN: all contain "flu" within the name Specific pt considerations: - age 6 months to 8 yrs give 2 doses if not previously vaccinated (4 wks apart) Pts with egg allergies: - can receive age appropriate inactivated vaccine. Do not use live vaccine Give vaccine as soon as it arrives but is preferred before October

Pyridostigmine

BN: mestinon Mainstay treatment in MG MOA: blocks the breakdown of acetylcholine (cholinesterase inhibitor) CI: mechanical intestinal or urinary obstruction Warning: CHOLINERGIC EFFECTS: salivation, lacrimation, excessive urination, diarrhea.

Mesalamine

BN:: Apriso, Asacol, Pentasa, Rowasa aminosalicylate or ulcerative colitis (best tolerated one) CI: hypersensitivity to salicylates or aminosalicylates

Hypertensive Crisis: Urgencies and Emergencies

BP >/= 180/120 Hypertensive emergency: life threatening - treat with IV medications (KD page 467) - decrease BP by no more than 25% (within the 1st hr) Hypertensive urgency: - treat with oral medications that has a short onset - Decrease BP gradually over 24 - 48 hrs

BP and Kidney disease in Diabetes

BP goal: < 130/80 if higher ASCVD risk (>/= 15%) and <140/90 if not Diabetes, HTN and NO albuminuria: - Thiazide + CCB + ACE I or ARB Diabetes with albuminuria (>/= 30) +/- HTN: - ACE I or ARB; if needed add thiazide or CCB

Non-drug Treatment for Sickle Cell

Blood transfusions: - the goal Hgb should be no higher than 10 post infusion - Risk is iron overload in which chelation therapy is needed Bone marrow transplant: - only cure for SCD but not widely used bc of invasiveness and cost

Adjuvants for Musculoskeletal Pain/Spasms

Baclofen: Lioresal Cyclobenzaprine: Amrix, Fexmid, Flexeril Tizanidine: Zanaflex Carisoprodol: Soma Methocarbamol (Robaxin)

Beta-blocker Selectivity - Beta-1 selective - Beta-1 and Beta-2 selective (non-selective) - Beta-1 and Beta-2 selective (non-selective) and alpha-1 blockers

Beta-1 selective - Atenolol (Tenormin) - Esmolol (Brevibloc) - Metoprolol tartrate (Lopressor) - Metoprolol succinate (Toprol XL) - Nebivolol (Bystolic) - Bisoprolol - Betaxolol - Acebutolol Remember: AMEBBA Beta-1 and Beta-2 selective (non-selective) - Propranolol (Inderal LA) - Nadolol (Corgard) - Timolol (Timoptic) Beta-1 and Beta-2 selective (non-selective) and alpha-1 blockers - Carvedilol (Coreg) - Labetalol

Antianginal Treatment

Beta-blockers: used 1st line in SIHD, avoid in Prinzmetal's angina CCBs: preferred drug for Prinzmetal's angina (chest pain due to vasospasm of coronary arteries, unpredictable and can occur at rest, often caused by cocaine. Can be used in SIHD when BBs are CI. Nitrates: Sublingual recommended of all patients for fast relief of angina Ranolazine; CI: liver cirrhosis with strong 3A4 inhibitors and inducers. Can cause QT prolongation. Not for acute chest pain

Labs to assess and monitor HIV

CD4+ T Lymphocyte Count HIV RNA Concentration

Treatment for Raynaud's Phenomenon Drugs that can worsen Raynaud's

CCBs - commonly nifedipine Can worsen Raynaud's - BB, bleomycin, cisplatin, sympathomimetics (amphetamines, pseudoephedrine, methamphetamines', cocaine)

Confidence interval (CI)

CI provides the same info about significance as the p-value, plus the precision of the result. Alpha and CI will correlate with each other CI = 1 - alpha Result is statically significant if the CI range does not include 0 for comparing difference data (means) Comparing ratio data (Relative risk, Odds ration, hazard ratio) result is statically significant if it does not include 1.

Cost-Minimization Analysis (CMA) vs Cost-Benefit Analysis (CBA) vs Cost-Effectiveness Analysis (CEA)

CMA: used when 2 or more interventions have demonstrated equivalence in outcomes and the costs of each intervention are being compared. Limited to only be able to compare alternatives with demonstrated equivalent outcomes CBA: compares benefits and costs of an intervention in terms of monetary units CEA: used to compare the clinical effect of two or more interventions to the respective costs. Most effective analysis used in literature - Cost Utility Analysis (CUA) is a specialized CEA that includes quality of life component of morbidity indices such as Quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs)

Late or Missed Oral Contraceptives - COC's - POP's

COC's: - 1 late or missed (<48 hrs since last dose): take one ASAP and take next dose on schedule (even if 2 one same day) - backup contraception NOT needed - no need for emergency contraception (EC) - 2 missed pills (>/= 48 hrs since last dose): take the most recent pill ASAP (discard any other missed pills), take next pill as scheduled (even if 2 one same day). - backup contraception needed x 7 days - consider EC if unprotected sex w/in 5 days POP's: - if > 3 hrs past schedule time take pill ASAP - backup contraception x 2 days - consider EC if unprotected sex w/in 5 days

Calcium Based Phosphate Binders

Calcium acetate (Phoslyra, PhosLo) and Calcium carbonate (Tums) FIRST LINE for hyperphosphatemia Take with meals TID and skip if meal is skipped ADE: hypercalcemia, constipation, N

Centrally-acting Alpha-2 Adrenergic Agonists

Decrease BP by stimulating alpha-2 adrenergic receptors in the brain and reducing sympathetic outflow or norepinephrine, which decreases SVR and HR. Clonidine (Catapres): commonly used for resistant HTN and in patients who can not swallow (dysphagia, dementia) since it is available in patch formulation Guanfacine ER (Intuniv) Methyldopa

Drug Treatment for Hepatitis C

Depends on HCV genotype preferred HCV regimens include 2-3 DAA with different MOAs usually 8-12 weeks - NS3/4A protease inhibitor ("-previr") - NS5A replication complex inhibitor ("-asvir) - NS5B polymerase inhibitor ("-buvir") do NOT use 2 drugs with the same MOA All protease inhibitors take with food - "Protease Inhibitors and Grub"

Treatment resistant depression

Depression that does not fully respond to 4-8 wks of treatment at therapeutic dosing. Consider: - changing to another antidepressant - increase the dose - use a combo with different MOAs - augment with buspirone or a low dose of an atypical antipsychotic (aripiprazole, olanzapine, quetiapine) augment with lithium

Basal insulins

Detemir: Levemir - onset 3 - 4 hrs, lasts about 1 day, no peak Glargine: Lantus, Toujeo, Basaglar - onset 3 - 4 hrs, lasts about 1 day, no peak Degludec: Tresiba - onset about 1 hr, lasts 42+ hrs, no peak Do not mix basal insulins

The Hydrophobic-Lipophilic Balance (HLB)

Determines the type of surfactant to use in an emulsion whether its w/o or o/w scored 0-20 surfactants with HLB <10 are more LIPID soluble and used for w/o emulsions (Low=Lipid) - taste of w/o emulsions not palatable, primarily used topically surfactants with HLB >10 are more WATER soluble and used for o/w emulsions (High=H2O) - oral formulations are typically o/w

Digoxin Antidote

Digoxin immune Fab (Digibind)

Dihydropyridine vs Non-Dihydropyridine CCBs

Dihydropyridine: - primarily used for HTN, chronic stable angina - end in "-pine," Amlodipine (Norvasc), Nicardipine IV (Cardene IV), Nifedipine (Adalat, Procardia) - cause peripheral arterial vasodilation which decrease SVR and BP Non-Dihydropyridine - primarily used to control HR in certain arrhythmias and sometimes used for HTN and angina - Verapamil (Calan), Diltiazem (Cardizem, Tiazac) - Negative inotropic (decrease force of contractions), negative chronotropic (decrease HR)

Antihistamines For Insomnia

Diphenhydramine: Benadryl Doxylamine: Unisom SleepTabs MOA: block histamine H1 receptors ADE: sedation, peripheral anticholinergic ADE (dry mouth, urinary retention, ect) Avoid in BPH, can worsen glaucoma

Type of Study Data: Continuous vs Discrete (Categorical)

Continuous data: has logical order with values that continuously increase or decrease by the same amount (HR) two types: 1. Interval data: has no meaningful 0 (ex Celsius temp) 2. Ratio data: has a meaningful 0 (ex HR, age, height, time, BP) Discrete (Categorical data): two types 1. Nominal (name): subjects are sorted by arbitrary categories (names) (ex male or female, yes or no data, martial status, mortality) 2. Ordinal (order): data is ranked in logical order (pain scale, NYHA functional class). In contrast to continuous date, ordinal data does not increase or decrease by the same amount

Snake bites: eastern coral snake, Texas coral snake, copperhead snake, rattlesnake

Crotalidae polyvalent immune FAB (CroFab) for copperhead and rattlesnake bites Do not use ice; do not cut/suck out venom; transport patient to healthcare facility

Ace Inhibitors

Captopril: Capoten Enalapril: Vasotec Lisinopril: Prinivil, Zestril Quinapril: Accupril Ramipril: Altace MOA: block the conversion of angiotensin I to angiotensin II resulting in decreased vasoconstriction and decreased aldosterone secretion. Decrease cardiac remodeling and improve LV function and DECREASE MORTALITY AND MORBIDITY BBW: injury and death to fetus, stop as soon as pregnancy detected. CI: hx of angioedema, do not use within 36 hours of sucubitril/valsartan (Entresto) Warnings: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis (avoid use) ADE: generally well tolerated, cough, hyperkalemia, increase SCr, hypotension, dizziness Monitoring: BP, K, renal function, s/sx of HF, angioedema

Typhoid fever

Caused by Salmonella typhi passed by food/water with contaminated feces Vaccines only 50-80% effective IM do >/= 2 weeks prior to travel Oral do >/= 1 week prior to travel LIVE VACCINES

Cholera

Caused by Vibrio cholerae "rice-water stools" most common symptom

Hypercalcemia of Malignancy

Certain CAs cause calcium to leach from the bone causing hypercalcemia and week bones (fractures) Mild hypercalcemia: tx with hydration and loop diuretics Moderate to severe hypercalcemia (calcium>12) tx - IV hydration - 1ST LINE IV bisphosphonates (pamidronate, zoledronic acid) - Denosumab (Xgeva not to be confused with prolia) - Calcitonin (Miacalcin)

How to chew nicotine gum

Chew slowly until there is a tingle or peppery flavor Park it in between the cheek and gum When the tingle or flavor goes away, begin chewing slowly until it returns and park again Repeat until most of the flavor or tingle is gone (about 30 minutes) Do not eat or drink 15 minutes before or during chewing

Assessing severity of liver disease

Child-Pugh Classification 0-15 - class A (mild) <7 - class B (moderate) 7-9 - class C (severe) 10-15

Myasthenia Gravis treatment

Cholinesterase inhibitors, specifically Pyridostigmine (mestinon). This increases ACh levels and helps decrease the symptoms and muscle weakness

Iron Chelation Treatment

Chronic blood transfusions can lead to iron overload, which damages the liver Drug therapy (oral) - Deferasirox (Exjade, Jadenu) - Deferiprone (Ferriprox)

Disopyramide

Class IA antiarrhythmic (NOT USED OFTEN) BBW: reserved for patients with life-threatening ventricular arrhythmias Anticholinergic effects

Flecainide

Class IC antiarrhythmic (NOT USED OFTEN) MOA: blocks Na channels BBW: proarrhythmic effects, do not use in chronic AFIB CI: structural heart disease including (HF and MI), concurrent use of ritonavir

Central Alpha-2A Adrenergic Receptor Agonists For ADHD

Clonidine ER (Kapvay), Clonidine IR (Catapres for HTN) Guanfacine ER (Intuniv) Warning: dose dependent CV effects (hypotension, bradycardia, syncope) sedation, drowsiness. Do not DC abruptly (can cause rebound HTN) ADE: somnolence, fatigue, dizziness, HA

P2Y12 inhibitors

Clopidogrel: Plavix (prodrug) Prasugrel: Effient (prodrug) Ticagrelor: Brilinta bind to the adenosine diphosphate (ADP) P2Y12 receptor on the platelet surface which prevents ADP-mediated activation of the GPIIb/IIIa receptor complex, thereby reducing platelet aggregation. Commonly used with aspirin after Acute Coronary Syndrome (ACS), which is called dual antiplatelet therapy (DAPT). They all require a much higher one time loading dose either prior to PCI or at the time of diagnosis if PCI is not being performed.

Concentration-Dependent Antibiotics

Cmax:MIC - Aminoglycosides - Quinolones - Daptomycin Goal: high peak (increased killing), low trough (decreased toxicity) Dosing Strategy: large dose, long interval

Treatment consideration for tobacco cessation: - weight gain - depression - dentures - Asthma/COPD - Skin conditions - Seizures - cost

Combo of patch + gum/lozenge or bupropion is more effective than patch alone - weight gain: use gum, lozenge and bupropion SR delay weight gain - depression: use bupropion SR - Dentures: avoid gum - Asthma/COPD: avoid inhaler or spray - skin conditions: avoid patch - seizures: avoid bupropion and varenicline - cost: avoid rx only: varenicline, bupropion SR, Inhaler, spray

Treatment of Chronic Systolic Heart Failure

Combo of: (ACEI or ARB or ARNI) + BB + loop diuretic +/- aldosterone antagonist usually added next if needed

Statins and DDI

DDIs increase the risk of muscle damage and other ADE Most DDI are CYP mediated and in general rosuvastatin and pravastatin have less DDIs Do not use simvastatin and lovastatin with CYP inhibitors like grapefruit, protease inhibitors, azole antifungals, cyclosporine, macrolides (except azithromycin), amiodarone (lower dose), non-DHP CCBs (lower dose)

Diabetic ketoacidosis and Hyperosmolar Hyperglycemia State

DKA is a life threatening crisis, with high BG, most common in T1D but can occur in T2D - recognizing DKA: - BG > 250 - ketones (urine and serum cause fruity breath), NV - Anion gap acidosis Hyperosmolar Hyperglycemic state (HHS) - less common and more prevalent in T2D - recognizing: - confusion, delirium - BG > 600 - Extreme dehydration - pH > 7.3, bicarbonate > 15

Stimulant Laxatives

DOC for Opioid Induced Constipation (+/- stool softener) - Senna: Ex-Lax, Senokot (+ docusate: Senna S) - Bisacodyl: Dulcolax

DTap, Tdap vaccine

DTap: Pediarix ("D" kids) - routine 5 doses: 2, 4, 6, 12-18 months and 4-6 yrs (for children younger than 7 - diphtheria toxoid, tetanus toxoid, acellular pertussis (+HepB-IPV) Tdap: Adacel, Boostrix ("d" adults) - >/= 11 if not previously received - routine booster every 10 years - Wound prophylaxis: for deep dirty wounds revaccinate with Tdap or Td if its been more than 5 yrs since lase dose - recommended in for each pregnancy

Rectal medication counseling

For best results empty bowel immediately before use Enemas: best results lay on left side with right leg flexed forward for balance. Insert tip into rectum pointed slightly to naval. Squeeze slowly to instill the med Remain in position for at least 30 mins Suppositories: insert pointed end 1st completely into rectum using gentle pressure, you can use a little bit of lube gel if needed For best results keep in rectum for 1-3 hrs

Clomiphene

For infertility and is 1st line tx in women with irregular or absent menstrual cycles. Selective Estrogen Receptor Modulator (SERM) - act as estrogen agonist on some tissues and estrogen antagonists on others. - MOA: causes LH and FSH to surge which triggers ovulation ADE: can cause hot flashes and clotting risks Gonadotropins used if no response to Clomiphene Can cause multiple eggs to be released (twins!)

Folic acid, folate, vitamin B9

For macrocytic anemia Warning: parenteral products may contain aluminum which can accumulate ADE: bronchospasm, flushing, rash, pruritus

Forest Plots and Confidence Intervals

Forest plots provide CI for difference data or ratio data Boxes estimate effect Diamonds represent pooled results from multiple studies Horizontal lines through the boxes illustrate the length of the CI for that particular study. The longer the line, the wider the interval, and the less reliable the study results Vertical lines is the line of no effect. A significant benefit has been reached when data falls to the left of the line, data to the right of the line indicates significant harm. The vertical line is set at 0 for difference data and at 1 for ratio data

MAJOR CYP INHIBITORS

G <3 PACMAN (enzyme inhibition is FAST) - Grapefruit - Protease inhibitors (ex ritonavir) - Azole antifungals - Cyclosporine, cimetidine, cobicistat - Macrolides (clarithromycin and erythromycin but not azithromycin) - Amiodarone (and dronedarone) - Non-DPH CCBs (diltiazem and verapamil) Effects on substrates - decreased metabolism - increased serum concentration - INhibitors=INcreased effects/levels/ADR/toxicity Effects on Prodrugs - decreased conversion to active metabolite

Adjuvants for Neuropathic pain

Gabapentin (Neurontin), Pregabalin (Lyrica) Warning: angioedema and suicidal thoughts and behavior. ADE: dizziness, somnolence, peripheral edema, weight gain. Carbamazepine (Tegretol) Milnacipran, Amitriptyline (Elavil), Duloxetine (Cymbalta)

Restasis

Generic: Cyclosporine Ophthalmic For dry eyes from Sjogren's syndrome ADE: ocular burning

Aminoglycosides Overview

Gentamicin, Tobramycin, Amikacin - MOA: bind to 30S subunit of ribosome to halt protein synthesis - Primarily cover gram - - Concentration depended killing (high Cmax wanted) - Synergistic with beta-lactams - Toxicities: nephrotoxicity and ototoxicity - if you give large doses less frequently this gives the kidneys time to recover between doses. - Renal dose adjustment for time interval

Drug Exposure

Get the drug or chemical off the person ASAP Remove the garb with drug on it Immediately cleanse any affected skin For eye exposure rinse for at least 15 minutes Obtain medical attention when warranted Document exposure in the employees record

Beta-blocker Antidotes

Glucagon if unresponsive to symptomatic treatment Same of CCBs

GOLD guidelines

Grading system to determine COPD severity based on FEV1

Anemia of CKD

HGB < 13 Cause: decreased EPO production TX: ESAs - epoetin alfa (procrit, epogen) - darbepoetin alfa (aranesp) Risks: elevated BP, thrombosis Should only be used when hgb < 10 and dose should be held of DCed if the hgb exceeds 11 Only effective if adequate iron is available to make hgb

Lab: hemoglobin (HGB)

HGB is the iron containing protein that carries O2 in the RBCs increases: ESAs decreases: anemias and bleeding

Human Papilloma virus vaccine

HPV9 (9-Valent) Gardasil 9 Recommended at age 11-12, may be started at 9 - 2 doses CI with severe yeast allergy

Monophasic Combination Oral Contraceptives (COC)

Have the same dose of estrogen and progesterone throughout the pill pack usually ethinyl estradiol (EE), and progestin (norethindrone, levonorgestrel, drospirenone)

Hepatitis A vaccine

Havrix, VAQTA children: routine, 2 doses at 12 months and 6-18 months later Adults: gay men, drug users, chronic liver disease

CHA2DS2-VASc

Helps determine if anticoagulation is needed

Garbing and Donning for Sterile Compounding

Don in anteroom area and do dirtiest to cleanest - don head and facial hair covers and face masks, then shoe covers while stepping over the line of demarcation. A second pair of shoe covers is needed for hazardous drugs (HD). - Perform hand hygiene for at least 30 seconds - Dry hands with lint-free disposable towels - Don gown. Disposable gowns required for HD. - Enter the buffer area (SEC) and apply alcohol based hand scrub. - Don sterile gloves. Two pairs required for HD's. Tuck one pair under the cuff of gown and the second over the cuffs. - Sanitize gloves with 70% IPA routinely during compounding.

Tetracyclines Overview

Doxycycline (Vibramycin), Minocycline (Minocin, Solodyn), Tetracycline - MOA: inhibit bacterial protein synthesis by binding 30S ribosome - Do not use in pregnancy, breastfeeding or children <8 DDI: antacids and other polyvalent cations chelate and inhibit absorption.

Nicotine Antidote

Early symptoms: ab pain, nausea later symptoms: bradycardia, dyspnea, lethargy, coma, seizures Supportive care: atropine for bradycardia, benzos for seizures

The ECHO Model

Economic: direct, indirect, and intangible costs of the drug compared to medical intervention Clinical: medical events that occur as a result of the tx or intervention Humanistic Outcomes: include consequences of the disease or tx as reported by the pt or caregiver

Activated Charcoal

Emergency treatment for some orally ingested drugs Most effective when used within one hour of ingestion The charcoal adsorbs the drug and prevents GI absorption and systemic toxicity Dose: 1g/kg - prior to administration the airway needs to be protected CI: - unprotected airway - unconscious pt - pt cannot clear throat - pt cannot hold head upright - intestinal obstruction - GI tract not intact or when there is decreased peristalsis

Hepatitis B vaccine

Engerix-B, Heplisav-B, Recombivax-HB (in Pediarix) 3 dose series started at birth, 1, and 2 Adults: healthcare workers, chronic liver disease, HIV, diabetes

Low Molecular Weight Heparins

Enoxaparin (Lovenox) Dalteparin (Fragmin) MOA: binds to AT, which inactivates Factor Xa and Factor IIa. The anti-factor Xa activity is much greater. Lovenox: prophylaxis VTE: 30 mg SC Q12 or 40 Qday tx of VTE or UA/NSTEMI: 1mg/kg SC Q12, QDay for CrCl<30 BBW: patients receiving neuraxial anesthesia (epidural, spinal) or undergoing spinal procedure are at risk for hematomas and subsequent paralysis CI: hc of HIT or major active bleed

Menopause Hormone Therapy and Appropriate Use

Estrogen: most effective for vasomotor symptoms. WOMEN WITH AN UTERUS USE IN COMBO WITH PROGESTERONE (PROGESTIN), unopposed estrogen increases the risk of endometrial cancer. Progestins: (norethindrone, levonorgestrel, drospirenone) can be given as a combo pill or single tablet (medroxyprogesterone most common). Criteria for use of hormonal therapy: healthy, symptomatic women who are within 10 year of menopause, </= 60 yo and no CI

Insomnia Guideline Recommendations

Eszopiclone and Zolpidem in all three groups

Anti-TNF Biologic DMARDs

Etanercept: Enbrel Adalimumab: Humira Infliximab: Remicade Certolizumab: Cimzia Golimumab: Simponi All given weekly besides Simponi (monthly) Used for a variety of diseases including RA Needles are provided Each has a pregnancy registry

Medications for Oral Complications of Chemotherapy - Oral Mucositis - Xerostomia

FOR ORAL MUCOSITIS Lidocaine 2% topical solution for mouth - BBW: avoid in pts <3 seizures, cardiopulm arrest and death - ADE: dizziness, drowsiness FOR XEROSTOMIA Pilocarpine (cholinergic)

Type 2 errors

False negatives the probability of a type 2 error, denoted as beta occurs when the null hypothesis was accepted when it should have been rejected The risk of a type 2 error increases when a sample size is too small. To decrease this risk, a power analysis is performed to determine the sample sized needed to detect a true difference between groups.

Type 1 errors

False positives the alternative hypothesis was accepted and the null hypothesis was rejected in error CI = 1 - alpha (type 1 error)

Bulk Forming Laxatives

First line for most cases including pregnancy - Psyllium: Metamucil - Calcium Polycarbophil: FiberCon - Methylcellulose: Citrucel - Wheat dextrin: Benefiber

Asthma reversibility

If a patient has asthma and their FEV1 increases more than 12% with the use of a bronchodilator it is considered reversible.

Classification of Cholesterol and TG Levels

If not fasting (9-12 hr fast) TG level can be falsely elevated which can cause incorrect LDL calculation Non-HDL: < 130 desirable LDL: < 100 desirable >/= 190 Very high HDL: >/= 40 (men) >/= 50 (women) Triglycerides: < 150 desirable >/= 500 very high

Treating hypoglycemia

If symptoms are present or a reading < 70 - Unconscious: - GlucaGen or Gvoke SC, IV or IM - Baqsimi nasal spray in one nostril - if IV access glucose using D5W - Conscious and can swallow - 15 grams of Glucose tab or gel - after 15 mins check BG and if < 70 repeat

If you need to apply more than one eye drop

If the same medication wait 5 minutes between drops If 2 different medications wait 5 - 10 minutes to put the second med in the eye. If a gel wait 10 minutes

Drug Treatment for Sickle Cell

Immunizations and antibiotics (prophylactic penicillin BID until age 5) to reduce infection risk, analgesics for pain and hydroxyurea to prevent or reduce the frequency of acute and chronic complications and chelation therapy to manage iron overload from blood transfusions Monoclonal antibodies: voxelotor, crinalizumab

KD that can worsen GERD symptoms

NSAIDs/aspirin, bisphosphonates, dabigatran, estrogen products, fish products, iron supplement, nicotine replacement therapy, steroids, tetracyclines

Non-selective beta blockers for portal HTN

Nadolol (Corgard), Propranolol (Inderal) BBW: do not withdrawal abruptly continue indefinitely

Antistaphylococcal Penicillins

Nafcillin, Oxacillin, Dicloxacillin - preferred for MSSA soft tissue, bone and joint, endocarditis, and bloodstream infections - no renal adjustments - Nafcillin is a vesicant

Who determines which drugs are hazardous?

National Institute for Occupational Safety and Health (NIOSH)

KDs Drugs and Conditions that can raise LDL or Triglycerides

Increase LDL and TGs - diuretics - efavirenz - steroids - immunosuppressants (cyclosporine, tacrolimus) - atypical antipsychotics - protease inhibitors Increase LDL only: - fish oils (except Vascepa) Increases TGs Only: - IV lipid emulsions - propofol - bile acid sequestrants Conditions: obesity, poor diet, hypothyroidism, alcoholism, smoking, diabetes, renal/liver disease, nephrotic syndrome

Antipsychotic Treatment Consideration - Cardiac/QT risk - HX of movement disorder (Parkinson disease) - Overweight/metabolic risk - Nonadherence or homeless

Need at least 4-6 weeks to determine efficacy Did it work and was it well tolerated? - if it did not work do not take again - do not use if poorly tolerated (ex painful gynecomastia with paliperidone/risperidone) Cardiac/QT risk: do not choose a QT prolonging drug (ziprasidone, haloperidol, thioridazine, chlorpromazine) HX of movement disorder (Parkinson disease): Quetiapine preferred Overweight/metabolic risk: not olanzapine or quetiapine (use aripiprazole, ziprasidone, lurasidone and asenapine) Nonadherence or homeless: choose a long acting injection

Empiric Antibiotics in Chemotherapy Patients

Need to be started immediately if a fever occurs Fever: >38.3C x 1 reading or 38C sustained for >1hr Neutropenia: absolute neutrophil count (ANC) <500 or ANC that is expected to decrease <500 in next 48hrs Low risk: expected ANC<500 - ORAL ciprofloxacin or lecofloxacin + amoxicillin/clavulanate or clindamycin (if allergic to penicillin High risk: expected ANC</=100, presence of comorbidities: IV anti-pseudomonal beta lactams - cefepime or ceftazidime or meropenem or imipenem/cilastatin or piperacillin/tazobactam

Lab: Mean Corpuscular Volume (MCV)

Increases: B12 or folate deficiency decreases: iron deficiency

Lab: RBCs

Increases: erythropoiesis-stimulating agents (ESAs), smoking, and in polycythemia decreases: chemotherapy that targets the bone marrow, blood loss, deficiency anemias (B12, folate), hemolytic anemia, sickle cell anemia

Changing the dosing interval for vaccines in a series

Increasing the interval: does not decrease the effectiveness of the vaccine but delays protection Decreasing the interval: can interfere with antibody response and protection

Independent and Dependent Variables

Independent variable is changed (manipulated) by the researcher in order to determine whether it has an effect on the dependent variable (the outcome) Independent variable exs: drug, drug dose, placebos, patients age, gender, comorbid conditions Dependent variable: HF progression, A1C, BP, cholesterol values, mortality

Controllers for asthma (maintenance drugs)

Inhaled corticosteroids: 1st line for all patients with persistent asthma inhaled long acting beta-2 agonist (LABAs): used in combo with ICS (should never be used alone) oral leukotriene receptor antagonist (LTRAs): most common in children, used in combo with ICS Theophylline (oral or IV): least desirable and requires monitoring of serum drug levels Inhaled long acting muscarinic antagonists (LAMAs): can be used as an add on treatment is pts with a hx of exacerbations despite ICS/LABA treatment Injectable MaB's: - omalizumab: for severe allergic asthma - mepolizumab, reslizumab, benralizumab, and dupilumab for eosinophilic asthma

Relievers for asthma (rescue)

Inhaled low-dose ICS-Formoterol Inhaled short acting beta-2 agonists (SABA) Inhaled epinephrine Inhaled short acting muscarinic antagonists (SAMAs) aka inhaled anticholinergics

Lab: C-peptide

Insulin breakdown product used to evaluate beta-cell function. Distinguishes type 1 from type 2 diabetes

Storage of vaccines

Keep in fridge or freezer and document temperature twice each workday and keep temp logs for 3 years Vaccines stored in freezer: - varicella, zostavax, MMRV (bc of the varicella component), oral cholera, ebola, smallpox and monkeypox

Hepatic encephalopathy TX

Lactulose ("-lose) 1st line followed by Rifaximin (Xifaxan) Lactulose - CI: low galactose diet - ADE: farts, D, dyspepsia, ab discomfort - Monitor: MS, BMs, ammonia Rifaximin - ADE: peripheral edema, dizziness, - Monitor: MS, ammonia

Methotrexate Antidote

Leucovorin (folinic acid) levoleucovorin (Fusilev)

Valproic acid or topiramate induced hyperammonemia antidote

Levocarnitine (Carnitor)

Bipolar disorder overview

Lithium and antiepileptic drugs (valproate, lamotrigine, and carbamazepine) treat both mania and depression without inducing either state. Antipsychotics are not traditional mood stabilizers can help when mania occurs with psychosis Antidepressants can induce mania as monotherapy and should only be used in combo with a mood stabilizer.

Live vaccines and PPD (aka TST) skin test

Live vaccines can cause a false-negative result, options include: - give the live vaccine as the same day of the skin test - wait 4 weeks after a live vaccine - admin skin test 1st, wait 48-72 hrs to get the result, then give the live vaccine

Tip for Contraceptive Brand Names - "Lo" - "Fe" - "24"

Lo: indicates </= 35 mcg E; less E causes less estrogenic side effects (Loestrin) Fe: indicates an iron supplement included (Loestrin Fe) 24: indicates a shorter placebo time: 24 active + 4 placebo = 28 day cycle (Minastrin 24 Fe)

Loop vs Thiazide vs Aldosterone Antagonists Diuretics

Loop - works on ascending limb of henle - stronger effect - long term use has a negative effect on bones (decreased bone density) Thiazide - works on distal convoluted tubule - weaker effect - long term use has a protective effect on bones Aldosterone Antagonists - works on distal convoluted tubule - increases serum K

Loperamide dosing for TD

Loperamide: Imodium A-D 4 mg after 1st loose stool and 2 mg after each subsequent loose stool up to a max of 16 mg/day by prescription or 8 mg/day OTC Can be used for self tx for up to 2 days, if symptoms persist see dr

Sterile Compounding Risks

Low risk sterile compounding: uses 1-3 components that are supplied as sterile from a manufacturer. Lowest contamination risk and longest BUD Medium risk sterile compounding: increases each time the bag is entered (when the bag is entered more than 3 times). ex parenteral nutrition bags High risk sterile compounding: not common and uses non-sterile ingredients that need to be sterilized prior to use. ex used for code blues and have short BUD

Surfactants

Lower the surface tension to make two ingredients more miscible. Does this by forming micelle structures which can reverse (turn inside out) Amphiphilic: hydrophilic on one side and hydrophobic on the other

Mineral oil

Lubricant laxative CI: < 6 y/o, pregnancy, bedridden pts, elderly, use > 1 wk, difficulty swallowing Onset: - oral: 6 - 8 hours - rectal: 2 - 15 minutes Oral formulations generally not recommended due to safety concerns (risk of aspiration and lipid pneumonitis)

SSRI DDI

MAOI's need a 2 week washout when starting SSRI, fluoxetine needs 5 weeks dues to its long t1/2. QT prolongation with citalopram (celexa) and escitalopram (lexapro) additive increased bleeding risk Fluoxetine (prozac) and paroxetine (paxil) are CYP2D6 inhibitors: Tamoxifen uses this 2D6

Macrocytic anemia

MCV > 100, caused by vitamin B12 or folate deficiency or both. Other causes (alcoholism, poor nutrition, GI disorders and pregnancy. Long term use of metformin, H2RAs or PPIs can decrease the absorption of vitamin B12. Vitamin B12 deficiency can result in serious neurological dysfunction. Folic acid deficiency causes ulcerations of the tongue and oral mucosa, and changes to skin, hair and fingernail pigmentation TX: Vitamin B12 (Cyanocobalamin) injections (1st line), folic acid (folate vitamin B9)

Meningococcal vaccines

MCV4 (conjugate vaccines) Menactra for age 9 months - 55 yo Menveo for age 2 months - 55 yo 2 dose series given at 11-12 and booster at 16 age 2 months and older for HIV, asplenia/sickle cell disease

Differences Between MDIs and DPIs

MDI: HFA, Respimat or no suffix DPI: Diskus, Ellipta, Pressair, Handihaler, Neohaler, Respiclick, Flexhaler

Measles, Mumps, Rubella Vaccines

MMR: M-M-R II MMRV (MMR + Varicella): ProQuad LIVE VACCINE SC

Chloramphenicol

MOA: 50S BBW: serious and fatal blood dyscrasias Warmings: Gray syndrome

Doxepin

MOA: TCA, primarily inhibit NE and 5-HT reuptake. They also block ACh and histamine receptors. CI: MAOI's, linezolid, IV methylene blue, glaucoma and urinary retention ADE: QT prolongation with OD, suicidal ideation, orthostasis - anticholinergic: dry mouth,, blurred vision, urinary retention, constipation, vivid dreams, weight gain, falls Tertiary Amines: slightly more effective but more anticholinergic properties (more likely to cause sedation and weight gain). Silenor: can be used for insomnia (off label)

Mitoxantrone

MOA: anthracycline, Cell Cycle Independent Drug, intercalates DNA inhibiting topoisomerase II and creating oxygen free radicals that damage cells Drug is blue and causes discoloration of urine, tears, sweat and salvia BBW: myocardial toxicities, myelosuppression, secondary malignancy

Unfractionated Heparin

MOA: binds to antithrombin, which then inactivates thrombin (factor IIa) and factor Xa and prevents the conversion of fibrinogen to fibrin Prophylaxis VTE: 5000 units SC Q8-12 Treatment of VTE: 80 units/kg IV bolus; 18 units/kg/hr infusion STEMI: 60 units/kg (4000 units max) Use total body weight for doing CI: active bleed ADE: bleeding, thrombocytopenia, HIT, alopecia, hyperkalemia and osteoporosis with long term use Monitoring: aPTT or anti-Xa level Antidote: protamine

Torsemide

MOA: block Na and Cl reabsorption in the thick ascending loop of Henle. They increase the excretion Na, K, Cl, Mg, Ca and water. The decrease fluid volume and make it easier for the heart to pump. BBW: can cause profound diuresis resulting in fluid electrolyte depletion CI: anuria Warning: sulfa allergy (not likely to cross react) ADE: decreased electrolytes K, Mg, Na, Cl, Ca - increased: HCO3, UA, BG, TG, total cholesterol - ototoxicity, orthostatic hypotension, photosensitivity Take early in day to avoid nocturia AVOID NSAIDS

Second Generation Antipsychotics

MOA: block dopamine (D2) and serotonin (5-HT2A) receptors. BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics Aripiprazole: Abilify Clozapine: Clozaril Lurasidone: Latuda Olanzapine: Zyprexa Paliperidone: Invega Quetiapine: Seroquel Risperidone: Risperdal Ziprasidone: Geodon Avoid drugs with higher metabolic risks if pts have diabetes or CVD Need a 4-6 week trial to determine efficacy Can be used alone or in combo with mood stabilizers for bipolar depression for acute mania

Fibrinolytics

MOA: cause fibrinolysis (clot breakdown) by binding fibrin and converting plasminogen to plasmin. Used for STEMI only. PCI in preferred if it can be performed within 90 minutes or within 120 minutes of first medical contact. If not possible than fibrinolytic is recommended and should be given within 30 minutes of hospital arrival. Alteplase: Activase Tenecteplase: TNKase

Hydralazine

MOA: direct vasodilator for HTN, vasodilates arterioles with little effect on the veins and decreases SVR and BP. CI: mitral valvular rheumatic heart disease, CAD Warning: Drug-induced lupus erythematosus ADE: peripheral edema, HA, flushing, palpitations, reflex tachycardia, NV

Lorazepam

MOA: enhance GABA, an inhibitory neurotransmitter, which caused CNS depression resulting in anxiolytic, anticonvulsant, sedative and/or muscle relaxant properties BBW: use with opioids can result in sedation, resp depression, coma and death. CI: SEVERE LIVER DISEAES (also for clonazepam), acute narrow-angled glaucoma, sleep apnea, resp depression Warning: dependence and tolerance, do not DC abruptly. CNS depression, crosses placenta ADE: somnolence dizziness, ataxia C-IV Antidote: Flumazenil Commonly used for alcohol withdrawal syndrome (Diazepam also)

Benzodiazepines for Anxiety

MOA: enhance GABA, an inhibitory neurotransmitter, which caused CNS depression resulting in anxiolytic, anticonvulsant, sedative and/or muscle relaxant properties Provide fast relief of symptoms Should only be used 1-2 WEEKS DUE TO RISK OF DEPENDENCE. Need to be tapered off if used for longer periods Beers Criteria: potentially inappropriate for pts >/=65, high risk of confusion, dizziness, and falls

SNRI and Brand Names

MOA: increase 5-HT by inhibiting its reuptake in the neuronal synapse and inhibit the reuptake of norepinephrine (NE) Venlafaxine: Effexor Duloxetine: Cymbalta Desvenlafaxine: Pristiq Levomilnacipran: Fetzima

Vinblastine

MOA: inhibit microtubules during M phase ADE: more associated with Bone marrow suppression (vin"B"lastine), autonomic neuropathy BBW: VESICANT, for IV only intrathecal admin is fatal myelosuppressive

Vincristine

MOA: inhibit microtubules during M phase Dose often capped at 2mg/dose ADE: CNS toxicity (vin"C"ristine), constipation, autonomic neuropathy BBW: VESICANT, for IV only intrathecal admin is fatal NOT myelosuppressive

Trazodone

MOA: inhibits 5-HT reuptake, blocks H1 and alpha-1 adrenergic receptors CI: MAOI's, linezolid, or IV methylene blue ADE: sedation, sexual dysfunction and risk of priapism (painful boner lasting longer than 4 hrs) rarely used an an antidepressant and primarily used off label for sleep

Labetalol

MOA: non selective BB and alpha-1 blocker, decreases HR and myocardial contractility and decrease peripheral vasoconstriction BBW: do not DC abruptly, taper over 1-2 weeks CI: severe hepatic impairment, severe bradycardia, 2nd or 3rd degree heart block Warnings: caution in diabetes, can increase or decrease BG and mask hypoglycemic symptoms. ADE: bradycardia, fatigue, hypotension, dizziness, depression, impotence, Raynaud's exacerbation edema, weight gain, dizziness

Cisplatin

MOA: platinum based compound, Cell Cycle Independent Drug, cross links DNA strands and inhibits protein synthesis. BBW: anaphylactic like reactions risk increases with each exposure Renal and ototoxicity doses >100 mg/m^2 highest incidence of NEPHROTOXICITY and CINV renally eliminated and needs to be adjusted ADE: peripheral neuropathy, NV

Carboplatin

MOA: platinum based compound, Cell Cycle Independent Drug, cross links DNA strands and inhibits protein synthesis. BBW: anaphylactic like reactions risk increases with each exposure Renal and ototoxicity doses >100 mg/m^2 renally eliminated and needs to be adjusted ADE: peripheral neuropathy, NV CALVERT formula to get AUC

Tricyclic Antidepressants

MOA: primarily inhibit NE and 5-HT reuptake. They also block ACh and histamine receptors. Tertiary Amines: slightly more effective but more ADE - Amitriptyline: Elavil - Doxepin Secondary Amines: more selective for NE - Nortriptyline: Pamelor

Bleomycin

MOA: topoisomerase II Inhibitor blocks DNA coiling in G2 phase MAX lifetime dose 400 units due to PULM TOXICITY BBW: PULM FIBROSIS, anaphylaxis ADE: hypersensitivity rxn (give small test dose) NOT myelosuppressive

First Generation Antipsychotics (FGA's)

MOA: work mainly by blocking dopamine-2 receptors (D2), with minimal serotonin (5-HT2A) receptor blockade Haloperidol: Haldol Chlorpromazine Thioridazine Loxapine Perphenazine Fluphenazine Thiothixene Trifluoperazine BBW: elderly pts with dementia related psychosis: increased risk of death from antipsychotics Warnings: QT prolongation, anticholinergic effects, CNS depression, EPS, hyperprolactinemia, NMS ADE: sedation, dizziness, anticholinergic effects Need a 4-6 week trial to determine efficacy

Calcium and Vitamin D

MUST SUPPLEMENT OSTEOPOROSIS DRUG TX WITH BOTH CALCIUM AND VITAMIN D Calcium: 1000 - 1200 mg elemental Ca daily recommended for most adults Calcium Carbonate (Tums, Oscal): 40% elemental calcium absorption: acid dependent must take with meals Calcium citrate (Citracal) 21% elemental calcium absorption: not acid dependent can take with or without food Vitamin D: vitamin D2 (ergocalciferol), vitamin D3 (cholecalciferol) treat deficiency with 5000 - 7000 IU daily or 50,000 IU weekly (can use either formulation) Required for calcium absorption Deficiency: serum vitamin D [25 (OH)D] < 30 ng/ml

Minimum Weighable Quantity

MWQ = Sensitivity Requirement / acceptable error rate

Alpha-2 Receptors - endogenous substrate - agonist action + examples - antagonist action + examples

Mainly Brain; central endogenous substrate: epinephrine, norepinephrine agonist action + examples: decreased release of epinephrine and norepinephrine, decreased BP (clonidine, brimonidine) antagonist action + examples: increased BP (ergot alkaloids, yohimbine

Beta-1 Receptors - endogenous substrate - agonist action + examples - antagonist action + examples

Mainly Heart endogenous substrate: epinephrine, norepinephrine agonist action + examples: increased myocardial contractility, CO and HR (dobutamine, isoproterenol, dopamine) antagonist action + examples: decreased CO and HR (beta-1 selective beta-blockers and non-selective beta-blockers (propranolol, carvedilol)

Beta-2 receptor - endogenous substrate - agonist action + examples - antagonist action + examples

Mainly Lungs endogenous substrate: epinephrine agonist action + examples: bronchodilation (albuterol, terbutaline, isoproterenol) antagonist action + examples: bronchoconstriction (non-selective BBs)

Alpha-1 Receptors - endogenous substrate - agonist action + examples - antagonist action + examples

Mainly peripheral endogenous substrate: epinephrine, norepinephrine agonist action + examples: smooth muscle vasoconstriction, increase BP. phenylephrine, dopamine antagonist action + examples: smooth muscle dilation, decreased BP. alpha1-1 blockers (doxazosin, carvedilol, phentolamine)

Bipolar disorder Maintenance Treatment

Maintenance tx should be initiated after the acute episode to prevent a relapse. Lithium and valproate are preferred for maintenance monotherapy, --but lamotrigine, carbamazepine and SGAs are alternatives During pregnancy lamotrigine or lurasidone is preferred because valproate, carbamazepine and lithium can cause harm to the fetus.

Master Formula Record vs Compounding Log

Master Formula Record: - what you should do Compounding Log - what you did

Measures of Central Tendency

Mean: average Median: middle number of ranked list Mode: Number that occurs most frequently

Depo-Provera

Medroxyprogesterone (Progestin Contraceptive) Given IM or SC every 3 months BBW: Loss of bone mineral density with long term use NO DDI because it bypasses first-pass metabolism

Drug TX T2D - HF - CKD - ASCVD/High risk

Metformin with lifestyle changes + - HF/CKD: SGLT-2i if eGFR > 30 (empagliflozin, canagliflozin dapagliflozin) - ASCVD: GLP-1 RA with CVD benefit - dulaglutide, liraglutide, semaglutide or - SGLT-2i if eGFR > 30 (empagliflozin, canagliflozin)

Geometric Dilution

Method used to blend two or more ingredients of unequal quantities to ensure that the ingredients are equally distributed throughout the mixture. A small mount of drug will be mixed into an equal amount of diluent and mixed evenly. Both will continue to be added until goal is reached. With multiple ingredients begin with the ingredient that has the smallest quantity (each time the amount is doubled)

Treating Acute Inflammation with Steroids (Medrol Therapy Pack)

Methylprednisolone - Pack contains 21 4mg tabs Day 1: 2 tab before breakfast, 1 after lunch, 1 after dinner, 2 at bedtime (6 total tabs) Day 2: 1 before breakfast, 1 after lunch, 1 after dinner, 2 at bedtime (5 total tabs) Day 3: 1 before breakfast, 1 after lunch, 1 after dinner, 1 at bedtime (4 total) Day 4: 1 before breakfast, 1 after lunch, 1 at bedtime (3 total) Day 5: 1 before breakfast, 1 at bedtime (2 total) Day 6: 1 before breakfast (1 total)

Maintenance of Remission Ulcerative Colitis

Mild: - Mesalamine (5-ASA) rectal and/or oral preferred Moderate: - Anti-TNF (infliximab, adalimumab, certolizumab) - thiopurine (azathioprine, mercaptopurine) - Methotrexate - IL receptor antagonist (Ustekinumab) - Janus Kinase Inhibitor (Tofacitinib - Xeljanz)

Maintenance of Remission Crohn's Disease

Mild: - oral budesonide for <= 3 months then DC and use thiopurine or methotrexate Moderate-severe - Anti-TNF (infliximab, adalimumab, certolizumab) - thiopurine (azathioprine, mercaptopurine) - Methotrexate - IL receptor antagonist (Ustekinumab)

Antidepressants and Pregnancy

Mild: psychotherapy Moderate - Severe: SSRI (except paroxetine [paxil] due to potential cardia effects). although preferred there is a warning regarding SSRIs for the risk of persistent pulmonary HTN of the newborn (PPHN)

Biphasic, Triphasic and Quadriphasic Combination Oral Contraceptives (COC)

Mimic the estrogen and progesterone levels during a menstrual cycle. Triphasic means the hormones change three times. usually ethinyl estradiol (EE), and progestin (norethindrone, levonorgestrel, drospirenone)

Lubricant Laxative

Mineral oil

Treatment for MS

Mitoxantrone Steroids to help with relapses (corticotropin) Disease modifying therapy: Interferon Beta formulations, glatiramer acetate (these two are the mainstay tx for patients with relapsing MS)

Vaccine contraindications and precautions

Moderate or severe illness: vaccine administration should be delayed Pregnancy and immunosuppression are CI for live vaccines timing of live vaccines and a pt who recently received antibody-containing blood product severe or anaphylactic reactions following a dose of that vaccine

KD Select drugs that increase K levels

Most common cause of hyperkalemia is kidney failure Symptoms of hyperkalemia: muscle weakness, bradycardia, fatal arrhythmias ACEi Aldosterone receptor antagonists Aliskiren ARBs Canagliflozin Drospirenone-containing COCs K containing IV fluids K supplements Bactrim Transplant drug (cyclosporine, everolimus, tacrolimus) Glycopyrrolate, Heparin, NSAIDs, Pentamidine

Missed doses patient counseling

Most med follow this general rule: if you miss a dose, take as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the next dose at your regular scheduled time. Do not take two doses at the same time unless instructed by your health care provider. Exceptions that do not follow this rule: high risk drugs (anticoagulants, transplant meds) oral contraceptives drugs that need to be taken at specific times (phosphate binders, pancreatic enzymes and prandial insulin that must be taken before a meal)

Muscle Damage and Statins

Muscle damage is the most important ADE Generally presents as muscle soreness, tiredness, or weakness, that is symmetrical in large adjacent muscle groups in the legs back and arms. - Myalgias, myopathy, myositis, rhabdomyolysis Reduce risk: avoid DDI, do not use simvastatin 80 mg/day, do not use gemfibrozil + statins

Number needed to treat (NNT)

NNT is the # of pts who need to be treated for a certain period of time in order for one pt to benefit NNT= 1 / ([risk in control group] - [risk in tx group]) or 1 / ARR EX. 10,111 pt were followed for 12 months. Metoprolol N=5123, HF progression=823. Control N=4988, HF progression=1397 Metoprolol risk= 823 / 5123 = 0.16 control risk= 1397 / 4988 = 0.28 ARR= 0.28 - 0.16 = 0.12 x 100 = 12% 1 / 0.12 = 8.3 rounded up to 9 for every 9 pts who received metoprolol for one year, HF progression is prevented in 1 case

Alpha blockers

NOT RECOMMENDED FOR HYPERTENSION but may be used in men who have hypertension and BPH. Bind alpha-1 adrenergic receptors which results in peripheral vasodilation of arterioles and veins. Doxazosin, Prazosin, Terazosin

Intermediate acting insulins

NPH - Humulin N - Novolin N - Onset 1 -2 hrs, peaks 4 - 12 hrs, lasts 6 - 10 hrs

The Null Hypothesis (H0) and Alternative Hypothesis (HA)

Null hypothesis: null means none or no, states NO STATISTICALLY significant difference between groups. Ex. a researcher studying a drug would write a null hypothesis that states there is no difference in efficacy between drug and placebo. The researcher tries to disprove or reject the null hypothesis Alternative hypothesis: states there is significant difference between the groups (drug efficacy does not equal placebo efficacy). This is what the researcher hopes to prove or accept These are complementary to each other, one is accepted and one is rejected

Tricyclic antidepressants (TCAs) OD Antidote

OD can cause fatal arrhythmias Sodium bicarbonate: to decrease widening of QRS complex Supportive care

Opioid Induced Constipation

OIC does not improve over time. Stimulant laxatives (senna (1st line) or bisacodyl) +/- a stool softener are recommended. - Peripherally-acting mu-opioid receptor antagonists (PAMORAs) help reduced constipation w/o affecting analgesia - Methylnaltrexone (Relistor) - Naloxegol (Movantik) - both CI in GI obstruction and warning for GI perforation. - Lubiprostone (Amitiza): chloride channel activator can be used after trials and failure with above.

Beta-blockers approved for chronic HF

ONLY THESE THREE FOR CHRONIC HF Bisoprolol (beta-1 selective) Carvedilol (non-selective and alpha-1) (Coreg) Metoprolol succinate (beta-1 selective) (Toprol XL)

KD Select Drugs that can cause Hemolytic Anemia

Occurs when RBCs are destroyed and removed from the bloodstream before their normal lifespan - can be drug induced, sickle cell disease, G6PD deficiency Direct Coombs test can detect antibodies that are stuck to the surface of RBCs cephalosporins, dapsone, isoniazid, levodopa, methyldopa, methylene blue, nitrofurantoin, pegloticase, penicillins, primaquine, quinidine, quinine, rasburicase, rifampin, sulfonamides

Acetaminophen Overdose

One of the most common causes of drug induced liver injury. Dose dependent ADE. NAPQI is the toxin that causes liver injury Phase 1 (1-24 hrs): commonly asymptomatic or NV Phase 2 (24-48 hrs): hepatoxicity evident on labs (elevated INR, AST/ALT) any symptom from phase 1 usually subsides Phase 3 (48-96 hrs): fulminant hepatic failure (jaundice, coagulopathy, renal failure and/or death) Phase 4 (>96 hrs): the pt recovers or needs liver transplant Antidote: N-acetylcysteine (NAC) given quickly: works by increasing glutathione - use the Rumack-Matthew nomogram to determine if NAC should be given

Codiene

Opioid - BBW: same as all opioids + do not use in children <12 and <18 following tonsillectomy/adenoidectomy - Prodrug for morphine and metabolized by 2D6

Drugs with Additive/Adverse CNS Depression Risks

Opioids, skeletal muscle relaxants, antiepileptics, BZDs, barbiturates, hypnotics, mirtazapine, trazodone, dronabinol, nabilone, propranolol, clonidine, sedating antihistamines, cough syrups with antihistamine or opioid, some NSAIDs, alcohol

Supraventricular Arrhythmias

Originate above the AV node and include: - sinus tachycardia - atrial fibrillation - atrial flutter - focal atrial tachycardias - supraventricular re-entrant tachycardias

Ventricular Arrhythmias

Originate below the AV node: - Premature ventricular contractions (PVCs) - Ventricular tachycardia - Ventricular fibrillation Further classified as with or without a pulse - pulse: tx with antiarrhythmics - no pulse: ACLS

Reactions that Cause Drug Degration

Oxidation-Reduction - Oxidation: loss of electrons - Reductions: gain of electrons - Prevent by: light protection, adequate storage, chelating agents, antioxidants, control pH Hydrolysis - when water causes cleavage of a bond in a molecule - Prevent by: protect from water, light protection, adsorbents (desiccants), lyophilizing powders, chelating agents, hygroscopic salt, prodrug formulation, control temp, control pH Photolysis: light protection

Comparing the P-Value to Alpha

P-value is compared to alpha if the alpha is set at 0.05 and the p-value is less than alpha (p<0.05), the null hypothesis is rejected and the result is termed statistically significant. If the p-value is greater than or equal to alpha (>/=0.05) the study has failed to reject the null hypothesis and the result is not statically significant

Drugs with Additive/Adverse Hypotension/Orthostasis Risks

PDE-5 inhibitors + 3A4 inhibitors or Nitrates or Alpha-1 blockers (doxasozin, terazosin)

Complications of Chronic Kidney Disease

PO4 levels increase bc kidneys cannot eliminate excess PO4. - TX: restrict dietary P and P binders Vitamin D cannot be activated by the kidney causing dietary Ca absorption to decrease. High PO4 and low Ca causes increased release of PTH. Ca if then pulled from the bones leading to increased fractures. As Ca increases and is not absorbed this can lead to CVD. - TX: Vitamin D and calcimimetic to decrease PTH Kidneys produce less EPO resulting in decreased RBC production in the bones which causes anemia. - TX: Iron and/or ESAs

MAJOR CYP INDUCERS

PS PORCS (takes 2-4 weeks and when inducer is stopped takes a while) - Phenytoin - Smoking - Phenobarbital - Oxcarbazepine (& eslicarbazepine) - Rifampin (& rifabutin, rifapentine) - Carbamazepine (also an auto-inducer) - St John's Wort Effects on substrate - increased metabolism - inDucers = Decreased effects/level of substrate Effects on prodrug - increased conversion to active metabolite

Emergency Contraception (EC)

Paragard IUD (copper IUD): 99.9% effective and use within 5 days Ella (ulipristal acetate): less effective if over 195 lbs, works better the sooner you get it (within 5 days) Plan B onestep or generic (levonorgestrel): less effective if over 165 lbs, take ASAP (within 3 days) - OTC with no age restrictions - MOA: prevents or delays ovulation and thickens cervical mucus. - ADE: N/V

Drugs with Additive/Adverse Anticholinergic Risks

Paroxetine, TCAs, 1st gen antipsychotics Sedating antihistamines (diphenhydramine, brompheniramine, chlorpheniramine, doxylamine, hydroxyzine, cyproheptadine) Atropine, belladonna, dicyclomine, meclizine Benztropine, trihexyphenidyl Muscle relaxants including baclofen, carisoprodol, cyclobenzaprine overactive bladder antimuscarinics such as oxybutynin, darifenacin, tolterodine

Which patches need to be removed prior to an MRI?

Patches containing metal bc it will burn the skin: Clonidine (Catapres-TTS) Diclofenac (Flector) Estrogen Rotigotine (Neupro) Scopolamine (Transderm Scop) Testosterone (Androderm)

Asthma Diagnosis

Peak flow meter BID over 2 weeks and is the PEFR variability is > 10% this suggests the dx of asthma

Beta-lactam antibiotics

Penicillins, Cephalosporins, Carbapenems - MOA: inhibit bacterial wall synthesis by binding to penicillin-binding proteins (PBPs). This prevents the final step of peptidoglycan synthesis in bacterial cell walls. - Monitor renal function, signs of anaphylaxis with 1st dose, CBC, LFTs with prolonged course

Beyond-Use Date

Nonaqueous Formulations (such as a drug in petrolatum): Not later than 6 months (180 days), store at room temp Water containing oral formulations (such as an oral suspension): Not later than 14 days when stored at controlled cold temps. Store in refrigerator. Water containing topical/dermal and mucosal liquid and semisolid formulation (such as cream or lotion): not later than 30 days. store at room temp. Some cause default BUD is not used: - if any ingredient decompose easily, select shorter BUD - if any ingredient expires before the BUD use the earlier expiration date - BUDs can extent if stability data is obtained

Gaussian Distribution

Normal distribution of bell shaped curve Characteristics: - curve is symmetrical - 68% of the values fall within 1 SD of the mean and 95% of values fall within 2 SDs of the mean

Polymyxins

Polymyxin B and Colistimethate - MOA: damages bacterial cytoplasmic membrane causing leakage and cell death - BBW: nephrotoxicity, neurotoxicity

Reduced absorption from polyvalent cations

Polyvalent cations: Mg++, Ca++, Fe++ (found in antacids, multivitamins, sucralfate, bile acid resins, aluminum, calcium, iron, magnesium, zinc, phosphate binders) should be separated from QUINOLONES, TETRACYCLINES, LEVOTHYROXINE, AND ORAL BISPHOSPHONATES.

COPD diagnosis

Post-bronchodilator FEV1/FVC < 70% Not fully reversible with mediation (asthma usually is)

Risk With Hazardous Drugs Risk With Sterile Drugs Risk With Non-Sterile Drugs

Risk With Hazardous Drugs: based on safety of staff Risk With Sterile Drugs: based on risk of contamination of the sterile product Risk With Non-Sterile Drugs: based on complexity of the preparation

Drug for travelers diarrhea

Prophylaxis: - bismuth subsalicylate 4 times daily with meals and at bedtime - Antibiotics (rifaximin preferred) only used if there is a high risk of complications from TD Treatment: - mild TD: loperamide or bismuth subsalicylate - moderate TD: loperamide +/- antibiotics (quinolines if low resistance, azithromycin or rifaximin) - severe TD (including dysentery: bloody diarrhea): antibiotics (azithromycin preferred, quinolones or rifaximin as alternatives) +/- loperamide

VTE Treatment Duration

Pts without cancer: dabigatran and the oral factor Xa inhibitors are preferred over Warfarin for the first 3 months Pts with cancer, LMWH is preferred over all oral anticoagulants

Peptic Ulcer First line Treatment

Quadruple therapy (take 10 - 14 days) - Bismuth subsalicylate 300 mg QID + - Metronidazole 250 - 500 mg QID + (or Tinidazole) - do use use alcohol with metronidazole - Tetracycline 500 mg QID + - do not use if pregnant or < 8 y/o - PPI BID Alternate Quadruple therapy (take 10 - 14 days) - Amoxicillin 1000 mg BID + - Clarithromycin 500 mg BID + - Metronidazole 250 - 500 mg QID + - PPI BID Triple therapy only used if local resistance rates to clarithromycin are low (<15%) and patient had not previous exposure to a macrolide.

Lipophilic Antibiotics

Quinolones, Macrolides, Rifampin, Linezolid, Tetracycline - large VD = excellent tissue penetration, including brain, lung and bone - hepatic metabolism = hepatotoxic and DDI - achieve intracellular concentrations = active against atypical (intracellular) pathogens - excellent bioavailability = IV:PO ratio often 1:1

Culture and susceptibility report

R= resistant (do not choose) S= susceptible (pick one of these) choose the "s" with the highest number ? so says pg 353

Rabies vaccine

RabAvert 2-3 dosed depending on exposure Post exposure to animal (without previous vaccination) 1 dose of rabies immune globulin (RIG) should be given with the 1st dose

Animal Bites Antidote

Rabies vaccine with human rabies immune globulin (HRIG)

Melatonin Receptor Agonists

Ramelteon (Rozerem) Tasimelteon (Hetlioz) MOA: agonists at the melatonin receptors, this promotes sleepiness and regulates circadian rhythm ADE: somnolence, dizziness Not a controlled substance

Spread (Variability) of Data

Range: difference between highest and lowest #s Standard Deviation (SD): indicates how spread out the data is and to what degree away from the mean. Data close to the mean has a smaller SD

Rapid acting insulins

Rapid acting - onset about 15 min, peak 1 - 2 hrs, lasts 3 - 5 hrs. - Aspart: Novolog, fiasp - Lispro: Humalog - Glulisine: Apidra - Inhaled: Afreeza - inject SC 5 - 15 mins before eating (lispro can be right after eating) Regular - onset about 30 mins, peak about 2 hrs, lasts 6 - 10 - Humulin R or Novolin R - inject 30 mins SC before meal - draw up first since its clear, in mixing with NPH

AFIB: Rate vs Rhythm Control and Stroke Prophylaxis

Rate control: patient remains in AFIB and takes meds to control ventricular HR (BB [preferred], non-DHP CCB and sometimes digoxin) Rhythm control: goal is to restore and remain in NSR Class Ia, Ic, or III antiarrhythmic or electrical cardioversion - If AFIB is permanent, avoid rhythm control antiarrhythmic drugs (risk > benefit) Stroke prophylaxis: for many patients it is safer to remain in AFIB and this will require anticoagulation: - NOAC (apixaban, rivaroxaban) are preferred over warfarin for non-valvular AFIB - Warfarin is indicated for mechanical heart valves

Red Book Orange Book Purple Book Pink Book Yellow Book Green Book

Red Book: drug pricing Orange Book: Approved Drug Products with Therapeutic Equivalence, interchanging generics Purple Book: list of licensed biologics with reference product exclusivity and biosimilars Pink Book: epidemiology and prevention of vaccine-preventable disease Yellow Book: Health information, for International Travel Green Book: information on approved animal drug products

Natural Products for Hyperlipidemia

Red yeast rice contains naturally occurring HMG-CoA reductase inhibitors OTC fish oils can be used to lower TGs but some products can increase LDL

Study Power

Power is the probability that a test will reject the null hypothesis correctly (ex the power to avoid a type 2 error) Power = 1 - beta As the power increases, the chance of a type 2 error decreases Power is determined by the number of outcome values collected, the difference in outcome rates between groups, and the significance (alpha) level. If beta is set at 20%, the study has 80% power (there is a 20% chance of making a type 2 error) Larger sample sizes increase the power and decrease the risk for type 2 errors

Neostigmine, Pyridostigmine Antidote

Pralidoxime (Protopam)

Correction factor (CF) for insulin

Regular 1500 / TDD insulin = CF for 1 u of regular insulin Rapid 1800 / TDD insulin = CF for 1 u of regular insulin [(BG now) - (BG target)] / CF = units needed

Drug Treatment for Acute Coronary Syndrome

Remember: MONA-GAP-BA M: morphine (antianginal, dilation, pain relief) O: oxygen N: nitrates (antianginal) A: aspirin (antiplatelet) Give MONA immediately G: GPIIb/III antagonists (abciximab, eptifibatide, tirofiban: antiplatelets) A: anticoagulants (LMWHs, UFH, and bivalirudin) P: P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) B: beta-blockers A: ACE I NSTE-ACE: MONA-GAP-BA +/- PCI (percutaneous intervention) STEMI: MONA-GAP-BA + PCI or fibrinolytic (PCI preferred)

KD Select Drugs that can Cause Drug-Induced Lupus Erythematosus (DILE)

Remember: My Pretty Malar Marking Probably Has A TransLent Quality Methimazole Propylthiouracil Methyldopa Minocycline Procainamide Hydralazine Anti-TNF agents (Etanercept: Enbrel, Adalimumab: Humira, Infliximab: Remicade, Certolizumab: Cimzia, Golimumab: Simponi) Terbinafine Isoniazid Quinidine

Statin Dosing Equivalents

Remember: Pharmacist Rock AT Saving Lives and Preventing Fatty-deposits Pitavastatin: 2 mg Rosuvastatin: 5 mg Atorvastatin: 10 mg Simvastatin: 20 mg Lovastatin: 40 mg Pravastatin: 40 mg Fluvastatin: 80 mg

Warfarin Tablet Colors

Remember: Please Let Greg Brown Bring Peaches To Your Wedding

KD Protect These Drugs from light during administration

Remember: Protect Every Necessary Med from Daylight - P: Phytonadione (vitamin K; mephyton) - Epoprostenol (Flolan) - Nitroprusside (Nitropress) - Micafungin (Mycamine) - Doxycycline

Direct Acting Antivirals (DAA) Mechanisms and Regimen

Preferred HCV regimens include 2-3 DAAs with different mechanisms (often in one tab). Be able to recognize appropriate and inappropriate combos. NS3/4A protease inhibitor - "-previr" P for PI - glecaprevir, grazoprevir, ect NS5A replication complex inhibitor - "-asvir" A for NS5A - Lediprasvir, ombitasvir NS5B polymerase inhibitor - "-buvir" B for NS5B - dasabuvir, sofosbuvir Protease inhibitors in HIV and HCV take with food

Hypertension Guideline Recommendations - when to start - goal BP - non-black patients - black patients - CKD (all races) - diabetes with albuminuria - when to start 2 drugs - Pregnancy

Pregnancy and BP >/= 160/105: - ACEI and ARBs CI - Labetalol and nifedipine ER are recommended (1dt line)

Immunologic Reactions to Monoclonal Antibodies

Premedicate with: - Acetaminophen (usually 650 mg PO) - Diphenhydramine (IV or PO)

Prevention drugs vs Treatment drugs for osteoporosis

Prevention: bisphosphonates (except IV ibandronate), estrogen based therapies, raloxifene, and Duavee Treatment: bisphosphonates, denosumab, parathyroid analogues (teriparatide, abaloparatide), and calcitonin must include adequate vitamin D and calcium intake

Key features of Quinolones - respiratory quinolones - antipseudomonal quinolones - moxifloxacin

Respiratory quinolone: - levofloxacin, moxifloxacin, gemifloxacin Antipseudomonal quinolones - ciprofloxacin and levofloxacin Moxifloxacin - only quinolone not renally adjusted - not used for UTIs caution in CVD, decrease K/Mg, and with other QT prolonging drugs. Avoid in pts with a seizure hx, children Watch for tendon rupture Avoid sunlight and separate from cations

CYP3A4 - substrates - inducers - inhibitors

Substrates: analgesics: fentanyl, hydrocodone, methadone, oxycodone anticoagulants: apixaban, rivaroxaban, warfarin CV: amiodarone, amlodipine immunosuppressants: cyclosporine, tacrolimus, sirolimus statins: atorvastatin, lovastatin, simvastatin HIV: atazanavir, ritonavir, efavirenz PD5i: avanafil, sildenafil, tadalafil, vardenafil ethinyl estradiol Inducers: carbamazepine, oxcarbamazepine, phenobarbital, phenytoin, rifampin, smoking, St. John's Wort Inhibitors: clarithromycin, erythromycin, azole antifungals amiodarone, diltiazem, verapamil cobicistat, ritonavir, protease inhibitors cyclosporine, grapefruit juice

CYP1A2 - substrates - inducers - inhibitors

Substrates: theophylline, warfarin Inducers: carbamazepine, phenobarbital, phenytoin, rifampin, smoking, St. John's Wort Inhibitors: ciprofloxacin, fluvoxamine

Stimulant Overdose Antidote

Supportive care for agitation or seizures (benzos)

Diagnosis of Osteoporosis

T-score: compares BMD to the average peak BMD of a healthy, young white adult of the same sex Measured by DEXA (or DXA) Interpretation Normal: >/= -1 Osteopenia: -1 - - 2.4 Osteoporosis: </= -2.5

Lab: Purified Protein Derivative (PPD)

TB skin test

Other Biologic DMARDs (Non-TNF inhibitors)

Rituximab: Rituxan (depletes CD20) Anakinra: Kineret Abatacept: Orencia Tocilizumab: Actemra Sarilumab: Kevzara

Key Vaccines In Sickle Cell Disease

Routine childhood series - Haemophilus influenzae type B (HIB) - Pneumococcal conjugate (PCV13, Prevnar) Additional vaccines for functional asplenia - meningococcal conjugate series plus routine boosters - meningococcal serogroup B - Pneumococcal polysaccharide (PPSV23, Pneunovax 23) - Pneumococcal conjugate (PCV13, Prevnar)

Insulin to carb ratio

Rule of 450 (for regular insulin) 450 / TDD of insulin = gms of carbs covered by 1 u Rule of 500 (for rapid acting insulin) 500 / TDD of insulin = gms of carbs covered by 1 u

KD Common drugs with diluent solution requirements SALINE VS DEXTROSE

SALINE (no dextrose) - A DIAbetic Can't Eat Pie - A: Ampicillin - D: Daptomycin (Cubicin) - I: Infliximab (Remicade) - C: Caspofungin (Cancidas) - E: Ertapenem (Invanz) - P: Phenytoin (Dilantin) DEXTROSE (no saline) - BOAS will strangle the pharmacists who puts these drugs into anything but dextrose - B: Bactrim (SMX/TMP) - Oxaliplatin - Amphotericin B - Synercid (Quinupristin/Dalfopristin)

Vaccine administration technique IM SC

SC: 23-25 gauge. 5/8" needle at a 45-degree angle. Inject into the fatty tissue over the triceps infants: inject into thigh IM: 22-25 gauge needle, 1 inch needle, inject 90-degree angle in deltoid - can use longer or shorter needle if too skinny or fat

Drugs that are dosed off eGFR

SGLT2 inhibitors and metformin generally is drugs need a renal adjustment they are dosed off of CrCl

***Organophosphates (including industrial insecticides) antidote***

SLUDD Symptoms: S: salivation L: Lacrimation U: urination D: diarrhea D: defecation Treatment Atropine (anticholinergic): blocks effects of ACh pralidoxime (relieves paralysis): reactivates cholinesterases Includes pesticides so people working on farms are at risk

Salicylates Antidote

Salicylates are acidic so sodium bicarbonate is an alkalinizing agent, this will decrease the drug reabsorption and increase the excretion of the salicylates

Statin Benefit Groups

Secondary prevention 1. clinical ASCVD: CHD (coronary heart disease), stroke, TIA, or peripheral arterial disease - high intensity statin Primary prevention 2. Primary elevation of LDL >/= 190 - high intensity statin 3. Diabetes and age 40-75 with LDL between 70-189 - multiple ASCVD risk factors: high intensity statin - Regardless of 10 year risk: moderate intensity 4. Age 40-75 with LDL between 70-189 - 10 year ASCVD risk >/=20%: high intensity - 10yearASCVD risk 7.5-19.9%+risk factors: moderate

Required Formulas

See page 26-27

Anaphylaxis Treatment

Seek immediate medical attention - epinephrine injection +/- diphenhydramine +/- steroids +/- IV fluids

Specificity

THE TRUE NEGATIVE how effectively a test identifies pts WITHOUT the condition. The higher the specificity the better chance the pt does NOT have the condition

Sensitivity

THE TRUE POSITIVE How effectively a test identifies pts with the condition. The higher the sensitivity the better (closest to 100%)

KD Drugs Most Commonly Associated with Thrombotic Thrombocytopenic Purpura (TTP)

TTP is a blood disorder in which clots form throughout the body. oral P2Y12 inhibitors (clopidogrel) sulfamethoxazole acyclovir famciclovir quinidine valacyclovir

KDIGO

Table does not need to be memorized but important to recognize that a GFR < 60 and/or albuminuria (AER >/= 30) indicated a pt has CKD

1st line treatment for PREMENOPAUSAL women with hormone-sensitive (ER+ or PR+ or ER+/PR+) breast cancer

Tamoxifen (selective estrogen receptor modulator - SERM) - estrogen antagonists in breast cells Aromatase inhibitors (AIs) do not ovarian estradiol production which is why they are NOT USEFUL for premenopausal women

Lipoglycopeptides

Telavancin: Vibativ Dalbavancin: Delvance Oritavancin: Orbactiv - MOA: glycopeptide that inhibits bacterial cell wall synthesis by binding to the D-alanyl-D-alanine cell wall precursor and blocking peptidoglycan polymerization - For gram positive only BBW: fetal risk: need pregnancy test first, nephrotoxicity CI: concurrent use of IV unfractionated heparin

KD Common drugs with filter requirements

That's my GAL, PLAT: - G: Golimumab (Simponi) - A: Amiodarone - L: Lorazepam - P: Phenytoin - L: Lipids (1.2 micron) - A: Amphotericin B (lipid formulations) - T: Taxanes (except docetaxel)

Main Organizations Involved in Medication Safety

The Joint Commission (TJC) Institute for Safe Medication Practices (ISMP)

Phosphate Binder DDI

Separate admin from levothyroxine and antibiotics that chelate (quinolones, tetracyclines) Ca bases phosphate binders interact with many drugs: quinolones, tetracyclines, oral bisphosphonates, and thyroid products

International Standards Organization (ISO)

Sets the standards for air quality - ISO 5: 3,520 particles/m^3 Primary engineering control (aka PEC, sterile hood or isolator) - ISO 7: 352,000 particles/m^3 Secondary engineering control (aka buffer room) - ISO 8: 3,520,000 particles/m^3 anteroom if it opens into a positive pressure SEC image page 241

Smoking and DDI

Smoking induces CYP1A2 and smokers who quit can experience side effects from supratherapeutic levels of caffeine, theophylline, olanzapine, clozapine, and the R-isomer of warfarin Smoking increases risk of bleeding with warfarin and clopidogrel women >/= 35 yo who smoke should not use estrogen containing contraceptives

Solution vs Suspension vs Emulsion

Solution: solute dissolved in a solvent (homogenous) - types: syrups, elixirs (ETOH+H2O), tincture (plant or animal extract dissolved in alcohol or hydroalcohol), spirits (alcohols or hydroalcohols that are volatile, evaporates easily) Suspension: solid dispersed in a liquid (heterogenous). A wetting/levigating agent is a type of surfactant. Redispersed easily by shaking Emulsion: liquid dispersed in liquid (heterogenous) (w/o or o/w). Precipitation/Sedimentation: when the dispersed phase settles (clumps) together. This can happen with suspensions and emulsions

DDI with hormonal contraceptives (decrease efficacy)

Some antibiotic: rifampin, rifabutin) Anticonvulsants: carbamazepine, oxcarbazepine, phenytoin, primidone, topiramate, lamotrigine) St. John's Wort Smoking tobacco Ritonavir-boosted protease inhibitors Colesevelam Byetta

Drugs with Additive/Adverse Hyperkalemia Risks

Spironolactone, eplerenone (highest risk) Renin-angiotensin-aldosterone drugs (ACEi, ARBs, aliskiren, sacubitril/valsartan) Amiloride, triamterene, salt substitutes (KCl), calcineurin inhibitors (tacrolimus and cyclosporine), canagliflozin, SMX/TMP

Treatment of ADHD

Stimulants are 1st line (take in the AM) - Methylphenidate (concerta, daytrana, ritalin), Lisdexamfetamine (vyvanse), Amphetamine + Dextroamphetamine (adderall) Non-stimulants are 2nd line Atomoxetine (Strattera) Add on medications or used alone (Central Alpha-2A agonists): - Guanfacine (Intuniv) - Clonidine (Kapvay) To help with sleep at night: - Clonidine IR (Catapres) - Diphenhydramine - Melatonin

Drug Treatment for Narcolepsy

Stimulants: - Modafinil: Provigil (ADE: severe rash) - Armodafinil: Nuvigil (ADE: severe rash) - Dextroamphetamine, dextroamphetamine/amphetamine and various methylphenidate formulations can be used Sodium Oxybate: Xyrem (REMS program)

CYP2C9 - substrates - inducers - inhibitors

Substrates: Warfarin Inducers: carbamazepine, phenobarbital, phenytoin, rifampin, smoking, St. John's wort Inhibitors: amiodarone, fluconazole, metronidazole, bactrim

CYP2C19 - substrates - inducers - inhibitors

Substrates: clopidogrel Inducers: carbamazepine, phenobarbital, phenytoin, rifampin inhibitors: esomeprazole, omeprazole

CYP2D6 - substrates - inducers - inhibitors

Substrates: codeine, meperidine, methadone, tramadol tamoxifen Inhibitors: fluoxetine, paroxetine

Time dependent antibiotics

Time > MIC (time dependent) - beta-lactams (penicillin's, cephalosporins, carbapenems) Goal: maintain drug level > MIC for most of the dosing interval Dosing strategies: shorter dosing interval, extended or continuous infusions

Janus Kinase Inhibitors

Tofacitinib (Xeljanz) Baricitinib (Olumiant) Upadacitinib (Rinvoq) MOA: inhibits janus kinase (JAK) enzymes, which stimulate immune cell function All PO and +/- methotrexate for RA BBW: serious infections, malignancies, thrombosis ADE: URTIs, UTIs, increased lipids DO NOT use with biologic DMARDs

Alpha Level

The standard for significance When investigators design a study, they select a maximum permissible error margin called alpha. Alpha is the threshold for rejecting the null hypothesis. Commonly set at 5% (or 0.05). Alpha correlates with the values in the tails with data has normal distribution

Classification of Asthma severity

This criteria can be used for patients >/= 12 follow up every 2 - 6 weeks initially and then decrease to 1 - 6 months when controlled and every 3 months if step down treatment is planned

Chemotherapy Cell Cycle Dependent Drugs

Topoisomerase I inhibitors (S phase) - Irinotecan (Camptosar) Topoisomerase II inhibitors (G2 phase) - Bleomycin Vinca alkaloids (M phase) - Vincristine - Vinblastine Taxanes (M phase) - Paclitaxel (Taxol) - Docetaxel (Taxotere) Pyrimidine Analog Antimetabolites (S phase) - Fluorouracil "5-FU" - Capecitabine (Xeloda) Folate metabolites (S phase) - Methotrexate (Trexall)

This drug is used for HER2 + breast cancer tumors

Trastuzumab (Herceptin) - prevents dimerization of HER2

Types of ADRs

Type A: dose dependent and predictable based on the drugs pharmacology - dose dependent related to known pharmacological actions. - The most common ADR - Ex orthostatic HTN from doxazosin (so titrate slowly) Type B: idiosyncratic - not predictable from drugs pharmacology - generally not dose dependent and influenced by patient specific factors. includes: - drug allergies (type 1-4) - pseudoallergic rxns (redmans syndrome with vancomycin) - drug intolerance (nausea with codeine) - idiosyncratic rxns (SJS)

Comparing Unstable angina, NSTEMI and STEMI

UA and NSTEMI: partial blockage STEMI: complete blockage

Antidotes for Anticoagulants - UFH - LMWH - Dabigatran - Apixaban - Rivaroxaban - Warfarin

UFH, LMWH: Protamine Sulfate Dabigatran: Idarucizumab (Praxbind) Apixaban, Rivaroxaban: Andexanet alfa (Andexxa) Warfarin: Vitamin K (do oral and avoid SC) or Phytonadione

Treatment for Psoriasis

UV light can improve mild-moderate Topical options: steroids, vitamin D analogs, anthralin, retinoids, salicylic acid, coal tar and moisturizers If these fail topical calcineurin inhibitors (Protopic, Elidel) can be tried (preferred for face) Severe cases: immunosuppressants: methotrexate, cyclosporine, hydroxyurea, or immunomodulators (Etanercept: Enbrel, Adalimumab: Humira, Infliximab: Remicade, Certolizumab: Cimzia)

Restless Leg Syndrome

Urge to move the lower legs, worse at night and relieved by movement. Caused by dopamine issues TX: IR Pramipexole (Mirapex) and IR Ropinirole (Requip) (dopamine agonists) Rotigotine (Neupro): patch ADE: orthostasis, somnolence and N Monitor: psychiatric ADE (hallucinations, abnormal dreams, movement disorders) Gabapentin (Horizant) approved for postherpetic neuralgia (PHN) and RLS

Exercise Induced Bronchospasm

Use SABA or low dose ICS plus formoterol taken 5 - 15 minutes before exercise

Ways to Reduce Systemic Steroid Risks

Use alternate day dosing Inject or apply directly to keep drug local for conditions in the gut, use a steroid with low systemic absorption (budesonide) for asthma use inhaled steroids used the lowest possible dose for the shortest duration possible

Prophylactic Gout Therapy

Use for patients who have experienced an attack and have intermittent symptoms or have tophi. When starting, colchicine or NSAIDs should have been used to reduce the risks of attacks. First Line drugs: - Allopurinol (Zyloprim, Aloprim) - Febuxostat (Uloric) Second Line: - Probenecid

Lab: Platelets

Used for blood clot formation and spontaneous bleeding occurs when platelets are <20,000 decreases: heparin, LMWH, fondaparinux, linezolid, valproic acid

Lab: Uric Acid

Used for diagnosis/treatment for gout increases: diuretics, niacin, low doses of aspirin, pyrazinamide, cyclosporine, tacrolimus, select pancreatic enzyme products, select chemotherapy (tumor lysis syndrome)

Lab: Prostate Specific Antigen (PSA)

Used in detecting prostate CA and BPH Can increase with testosterone supplementation

Loop diuretics

Used often in HF MOA: block Na and Cl reabsorption in the thick ascending loop of Henle. They increase the excretion Na, K, Cl, Mg, Ca and water. The decrease fluid volume and make it easier for the heart to pump. They do not increase survival but often needed for symptom control. The lowest effective dose should be used to prevent over-diuresis, which can cause hypotension or renal impairment If response to loop diuretic is poor, adding a thiazide can be helpful Furosemide: Lasix Bumetanide: Bumex Torsemide

Lab: Glucose-6-phosphate dehydrogenase (G6PD)

Used to determine if hemolytic anemia is due to G6PD deficiency G6PD deficiency triggered by stress, foods (fava beans) or these drugs: dapsone, methylene blue, nitrofurantoin, pegloticase, primaquine, rasburicase, sulfonamides

Lab: Direct Coombs Test

Used to determine the cause of hemolytic anemia (autoimmune vs drug induced) Positive: drug induced hemolysis caused by penicillins and cephalosporins, dapsone, isoniazid, levodopa, methyldopa, methylene blue, nitrofurantoin, pegloticase, primaquine, quinidine, quinine, rasburicase, rifampin, and sulfonamides

Lab: WBCs

Used to diagnosis and monitor infection/inflammation increases: systemic steroids, CSFs, epinephrine decreases: clozapine, chemotherapy, carbamazepine, DMARDs

Lab: Prothrombin Time / International Normalized Ratio (PT/INR)

Used to monitor Warfarin increases INR: liver disease, warfarin many drugs can increase or decrease INR False elevations: daptomycin, oritavancin, telavancin

Can patches be cut?

Usually NO, except lidoderm Do not expose to heat, apply to irritated skin or recently shaved areas

Varicella vaccine

Varivax (for chickenpox) 2 doses (12-15 months and 4-6 yrs) Do not use in Pregnancy or immunocompromised (LIVE VACCINE) SC

Add on Treatment to Statin

Very high risk and statin at maximum dose and LDL remains > 70 mg/dL: Ezetimibe (preferred) or PCSK9 inhibitors (Alirocumab = Praluent, Evolocumab = Repatha) Primary hypercholesterolemia (LDL >/= 190), statin at max dose and LDL remains >/= 100: Ezetimibe (preferred) or PCSK9 inhibitors (Alirocumab = Praluent, Evolocumab = Repatha) Fish oils and fibrates are used to treat higher triglycerides and bile acid sequestrants are rarely used except when statins cannot be tolerated.

Lab: Eosinophils

WBC with differential increased in drug allergy, asthma, inflammation, PARASITIC infection

Lab: Basophils

WBC with differential increased in inflammation, HYPERSENSITIVITY RXN

Lab: Lymphocytes

WBC with differential increased in viral infections, lymphoma decreased in bone marrow suppression, HIV or due to systemic steroids

Clotting Factors Drugs Inhibits - Warfarin - Rivaroxaban - Apixaban - Betrixaban - Fondaparinux - Unfractionated Heparin (UFH) - Enoxaparin - Dalteparin - Argatroban - Bivalirudin - Dabigatran

Warfarin (Coumadin, Jantoven): inhibits factors II (2), VII (7), IX (9), and X (10) Rivaroxaban (Xarelto), Apixaban (Eliquis), Betrixaban (Bevyxxa): directly inhibit factor Xa (10a) Fondaparinux (Arixtra): indirectly inhibits Xa (10a) via antithrombin Unfractionated Heparin (UFH); LMWH (Enoxaparin: Lovenox; Dalteparin: Fragmin): inhibit Xa (10a) and thrombin (IIa) Direct thrombin inhibitors (IIa): Argatroban (IV/SC), Bivalirudin (Angiomax IV/SC), Dabigatran (Pradaxa)

Asthma Treatment Algorithm

Well-controlled: maintain step and if controlled for 3 months may step down - Symptoms/SABA rescue use </=2 days/week, night time awakenings </=2 nights/month, no limitation on activity Not well-controlled: step up 1 step - Symptoms/SABA rescue use > 2 days/week, night time awakenings 1 - 3x/week, some limitation on activity Very poorly controlled: step up 1 - 2 steps - symptoms/SABA uses several times a day, night time awakenings >/= 4x/week, normal activities extremely limited

Types of Surfactants

Wetting agents: reduce the ST between a liquid and a solid to permit more easy spread. Emulsifiers: two or more liquids that are immiscible and these help keep the liquids mixed throughout and helps prevent the liquids from separating out Suspending agents (aka dispersants): a solid dispensed in a liquid, help keep solid particles from settling - Ora-Plus and Ora-Sweet Levigating agents: used to aid in grinding down particles of (glycerin and propylene glycol for aqueous compounds or mineral oil for oil-soluble) Foaming agents: help form foam by lowering ST of water.

Adverse Drug Reaction

a term that encompasses all UNINTENDED pharmacological effects of a drug when it is administered correctly and used at recommended doses. Do not confuse with medication errors.

carboxyl

acidic functional group

imide

acidic functional group

phenol

acidic functional group

sulfonamide

acidic functional group

Comminution

act of reducing a substance to small, fine particles - Trituration: grind into a small powder - Levigation: just like trituration but with a levigating agent (liquid) resulting in a paste. - Pulverization by intervention: used for crystalline powders that do not crush easily. The crystals are dissolved with the solvent and mixed until the solvent evaporates, leaving the finer crystals

Vaccinations for older adults

annual flu vaccines recommended for everyone >/= 6 months Herpes zoster vaccine - Shingrix (preferred): age >/= 50, 2 doses, 2-6 months apart - Zostavax: age >/= 60 Pneumococcal vaccine (age >/=65) - Pneumovax 23 x 1 (wait at least 1 year after prevnar 13, if given, and at least 5 years after any prior dose of Pneumovax 23) - Prevnar 13 x 1 (if immunocompromised and not previously received; optional for other adults)

Vaccinations for Adolescents and Young Adults

annual flu vaccines recommended for everyone >/= 6 months Meningococcal vaccine (MCV4, Menactra, or Menveo) - 2 dose, one at 11-12 and one at 16 - 1st year college students in residential housing if not previously vaccinated (one dose) HPV recommended at 11-12 - 2 or 3 doses depending on age start Tdap: 1st dose at age >11

Vaccinations for diabetes

annual flu vaccines recommended for everyone >/= 6 months Pneumococcal vaccine - before age 65 yrs: 1 dose of pneumovax 23 Hepatitis B: age 19-59

Monoamine Oxidase Inhibitors

block the metabolic breakdown of dopamine, norepinephrine, and serotonin Phenelzine (Nardil), Tranylcypromine (Parnate) and isocarboxazid (Marplan) are restricted to patients with depression unresponsive to standard tx Can cause Serotonin syndrome with drugs that increase serotonin or Epi and tyramine-rich foods (CI for all). Symptoms: severe nausea, dizziness, HA, D, agitation, tachycardia or hallucinations 2 week washout for: SSRIs, SNRIs, TCA, Bupropion 5 week for fluoxetine (prozac)

Relative risk reduction (RRR)

calculated after the RR and indicates how much the risk is reduced in the tx group compared to the control group RRR = ([%risk in control group] - [%risk in tx group]) / (%risk in the control group) or 1 - RR (must use decimal form)

Primary chemotherapy drugs used for breast cancer

capecitabine, carboplatin, cyclophosphamide, docetaxel, paclitaxel, doxorubicin, and methotrexate

which compounds are likely to become oxidized?

compounds with hydroxyl (-OH) (alcohol) group directly bonded to an aromatic ring (they become a =O) catecholamines such as epinephrine, phenolics such as phenylephrine, and aldehydes

DOC for severe SSTI requiring IV treatment or hospitalization

cover MRSA and streptococci - Vancomycin - Linezolid - Daptomycin - Ceftaroline

Lab: Albumin

decreased due to cirrhosis and malnutrition serum level of highly protein bound drugs (warfarin, calcium, phenytoin) are impacted by low albumin. The serum concentrations need correction for low albumin

Lab: Vitamin D (serum 25(OH))

decreased vitamin D increases your risk for osteoporosis, osteomalacia (rickets)

Cushing Syndrome and Long-term Effects of Steroids

develops when the adrenal gland produces too much cortisol or when exogenous (ie taken a drug) steroids are taken at high doses (opposite of Addison's disease).

Insulin or other hypoglycemics antidote

dextrose, glucagon

Most common cause of CKD

diabetes and HTN

Hydrocarbons: petroleum products (gas, kerosene, mineral oil, paint thinners Antidote

do not induce vomiting; keep pt NPO

NSAIDs and the Ductus Arteriosus

do not use NSAIDs in the third trimester of pregnancy because they can prematurely close the DA. After birth the DA should close on its own.

LABAs for COPD

do not use as monotherapy is asthma Salmeterol: Serevent Salmeterol + fluticasone: Advair Formoterol: Perforomist Formoterol + Budesonide: Symbicort Vilanterol + Fluticasone: Breo Ellipta

Nicotinic Receptor - endogenous substrate - agonist action + examples - antagonist action + examples

endogenous substrate: acetylcholine agonist action + examples: increased HR and BP. nicotine antagonist action + examples: neuromuscular blockade. neuromuscular blockers (rocuronium)

Muscarinic Receptor - endogenous substrate - agonist action + examples - antagonist action + examples

endogenous substrate: acetylcholine agonist action + examples: increased SLUDD (salivation, lacrimation, urination, diarrhea, defecation, and digestion - pilocarpine, bethanechol antagonist action + examples: decreased SLUDD (anticholinergic). atropine, oxybutynin

Dopamine Receptor - endogenous substrate - agonist action + examples - antagonist action + examples

endogenous substrate: dopamine agonist action + examples: many including renal, cardiac, and CNS effects (levodopa, pramipexole) antagonist action + examples: many including renal, cardiac, and CNS effects (1st gen antipsychotics, metoclopramide)

Serotonin Receptor - endogenous substrate - agonist action + examples - antagonist action + examples

endogenous substrate: serotonin (5-HT) agonist action + examples: many including platelet, GI, and psychiatric effects (triptans) antagonist action + examples: many including platelet, GI, and psychiatric effects (ondansetron, 2nd gen antipsychotics)

Lab: Alanine Aminotransferase (ALT)

enzyme released from injured hepatocytes

Lab: Aspartate Aminotransferase (AST)

enzyme released from injured hepatocytes

which compounds are likely to become hydrolyzed?

esters, amides, beta lactam rings

NuvaRing

ethinyl estradiol/etonogestrel vaginal contraceptive Insert monthly, leave in three weeks and take out for one Lower AUC than pills (Patch has higher AUC than pills and BBW: increased risk of thromboembolism) ADE: N, breast tenderness/fullness, bloating, weight gain, elevated BP - severe: thrombosis, stroke, DVT, MI Progestin ADE: breast tenderness, HA, fatigue, changes in mood. if late cycle breakthrough bleeding occurs an increase progestin dose may be needed BBW: do not use in women > 35 y/o who smoke due to risk of serious CV events

Tumor Lysis Syndrome

When a tumor lysis potassium, phosphate, purines and pyrimidines enter the blood stream TLS causes acute hyperkalemia, hyperphosphatemia and hypocalcemia Allopurinol (xanthine oxidase inhibitor) blocks conversion of purines to uric acid and in TLS the dose is much higher than that of gout. - gout ~ 100 mg/day - TLS ~ 400-800 mg/day

Amiodarone DDI

When starting amiodarone, decrease digoxin by 50% and decrease warfarin by 30-50%. Do not exceed 20 mg/day of simvastatin or 40 mg/day of lovastatin Sofosbuvir can enhance the bradycardic effects of amiodarone, do not use together

Absolute risk reduction (ARR)

more useful because it includes the reduction in risk and the incidence rate of the outcome ARR= (%risk in control group) - (%risk in tx group) EX. 10,111 pt were followed for 12 months. Metoprolol N=5123, HF progression=823. Control N=4988, HF progression=1397 Metoprolol risk= 823 / 5123 = 0.16 control risk= 1397 / 4988 = 0.28 ARR= 0.28 - 0.16 = 0.12 x 100 = 12% meaning 12 out of every 100 pts benefit from the tx or for every 100 pts tx with metoprolol, 12 fewer pts will have progression to HF

Alcohol-associated liver disease treatment

most important: alcohol cessation Inpatients: benzos outpatients: anticonvulsants to prevent relapse: - naltrexone (vivitrol) - acamprosate (campral) - disulfiram (antabuse)

Polio

most people in the US get their vaccine during childhood CDC recommends a single lifetime booster at least 4 weeks prior to traveling to high epidemic regions

Malaria advance start

must be started 1-2 wks prior to travel

Genetics that cause a higher risk for breast cancer

mutations in BRCA1 or BRCA2 genes - these genes normally suppress tumor growth males with Klinefelter syndrome (they have 2 or more X chromosomes)

ketone

neutral function group

aldehyde

neutral functional group

amide

neutral functional group

carbamate

neutral functional group

carbonate

neutral functional group

ether

neutral functional group

nitrate

neutral functional group

thioether

neutral functional group

urea

neutral functional group

Treatment of RA - non-drug - symptomatic

non-drug: rest, PT, OT, exercise, diet, weight control, surgical intervention Symptomatic: if they have symptoms place them on disease modifying antirheumatic drug (DMARD) regardless of the severity of disease - Methotrexate is the PREFERRED INITIAL THERAPY for most pts If moderate or high disease activity despite MTX a combo of DMARDs or a TNF inhibitor biologic, NEVER include 2 biologic DMARDs in combo steroids can be used to bridge but should be used in low doses and shortest duration possible

Air changes for compounding

non-sterile: at least 12 air changes per hour (ACPH) sterile: at least 30 ACPH

Isoniazid antidote

pyridoxine (vitamin B6)

Lab: Luteinizing Hormone (LH)

rises mid cycle, causing egg release from the ovaries (ovulation)

Select drugs and conditions that alter vital signs

see page 118

Compensatory mechanisms in hypertension

see page 454

Common Prodrugs and their Active Metabolites

see page 64

Inhibitors increase substrate of drug

see page 69

Common Toxicities of Select Chemotherapy Agents

see page 812-813

Selecting a test to analyze the data

see pg 223

Study types, Benefits and Limitations

see pg 227

Vaccine Contraindications and Precautions

see pg 329

Common Enzyme Targets for Medications

see pg 52

Therapeutic Drug Levels Carbamazepine Digoxin Gentamicin Lithium Phenytoin/Fosphenytoin Procainamide Tobramycin Valproic acid Vancomycin Warfarin

see pg 84

SSRI's Brand Generic

selective serotonin reuptake inhibitors MOA: increase 5-HT (serotonin) by inhibiting its reuptake in the neuronal synapse Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Paroxetine (Paxil) Sertraline (Zoloft) Fluvoxamine

Smoking cessation behavioral counseling

should be used for every patient behavioral counseling over medications for pregnant women, adolescents, smokeless tobacco users, and light smokers <10 cigs/day

Vaccinations in smokers

smokers 19 - 64 should receive the pneumococcal polysaccharide vaccine (Pneumovax 23) and an influenza vaccine

Dosage forms that are sterile and non-sterile

sterile: - IV - Eye drops - pulmonary inhalations non-sterile - oral - topical - nasal

Intolerance

stomach and upset stomach is often incorrectly reported as an allergy but it is an intolerance. Try to avoid the drug but does not mean you need to avoid other drugs from the class.

Anticholinergic OD antidote

supportive care and rarely physostigmine symptoms: dry skin and mucus membranes, mydriasis, blurred vision, altered mental status , fever

Lab: Human Chorionic Gonadotropin (hCG)

test in blood or urine to test for pregnancy

Addison's Disease

the adrenal gland is not making enough cortisol (opposite of Cushing syndrome) If exogenous steroids are stopped suddenly, it can cause addisonian crisis

Chemotherapy Cell Cycle Independent Drugs

the cell cycle does NOT affect the drugs killing Alkylating agents: - Cyclophosphamide (Cytoxan) - Ifosfamide (Ifex) - Carmustine (BiCNU) - Busulfan (Myleran) Platinum based compounds - Cisplatin - Carboplatin Anthracyclines - Doxorubicin (Adriamycin) - Mitoxantrone

Opioid allergy

the common drugs in the same chemical class that cross-react with each other have "cod" or "morph" (buprenorphine has "norph" instead"

Lab: Thiopurine Methyltransferase (TPMT)

those with TPMT deficiency at risk for myelosuppression and may require lower doses of azathiopurine and mercaptopurine

Regression

three types 1. linear for continuous data 2. Logistic for categorial data 3. Cox regression, for categorial data in a survival analysis

LAMAs for COPD

tiotropium: Spiriva Aclidinium: Tudorza Glycopyrrolate: Seebri, Lonhala Revefenacin: Yuperlri Umeclidinium: Incruse Ellipta

Lab: Creatine Kinase or Creatine Phosphokinase (CK or CKP)

to assess muscle inflammation or more serious muscle damage and to diagnose cardiac conditions increases: daptomycin, statins, tenofovir, reltegravir, dolutegravir

Continuous data

type of test to determine statistical significance Nonparametric method: data that is not normally distributed Parametric method: data is normally distributed T-test for 2 independent samples Analysis of Variance (F test) for 3 or more samples or groups

IV Drug filters

used for drugs that have a risk of particulates, precipitates, crystals, contaminants or entrapped air in the final solution 0.22 micron filter 1.2 micron filter for lipids

Lab: Bilirubin, total

used to monitor drug toxicity, determine other cause of liver damage and detect bile duct blockage

Lab: Activated Partial Thromboplastin Time (aPTT or PTT)

used to monitor unfractionated heparin and direct thrombin inhibitors

Invalid contraindications to vaccinations

vaccinations may be given, if indicated, in the following situations: - mild acute illness (slight fever, mild diarrhea) - current antimicrobial tx - previous local skin rxn (mild/moderate) from vax - allergies: bird feathers, penicillin, allergies to products not in the vaccine - Pregnancy (except live vaccines), breastfeeding, preterm birth - recent tuberculin skin test - immunosuppressed person in the household - family hx of adverse events to the vaccine

Vaccine timing and chemotherapy

vaccines during chemotherapy must be avoided vaccinations should precede chemotherapy by >/=2 weeks Live vaccines can generally be administered at least 3 months after chemo but should must be avoided during chemo

Lab: Troponin

for diagnosis of MI

Loop Diuretics Oral Equivalent Dosing

furosemide (lasix) 40 mg = torsemide 20 mg = bumetanide (Bumex) 1 mg = ethacrynic acid 50 mg Furosemide IV:PO = 1:2

Do not use estrogen with these conditions

history of DVT/PE, stroke, CAD, thrombosis of heart valves or acquired hypercoagulopathies history of breast, ovarian, or liver cancer, liver disease; uncontrolled HTN, severe headaches or migraines with aura; diabetes with vascular disease; unexplained uterine bleeding

Ethanol (alcoholic drinks) Antidote

if chronic drinker use thiamine (vitamin B1) to prevent Wernicke's encephalopathy

Ear drop counseling

if cold, gently roll in hands to warm up bc cold drops can be uncomfortable and cause dizziness Adults: gently pull ear lobe UP and BACK Kids (<3 yo): gently pull ear lobe DOWN and BACK Keep the affect ear facing up for about 5 minutes to allow medication to get down

Thiopurines

immunosuppressive drugs sometimes referred as immunomodulators. Used for induction and maintenance of remission in Crohn's and Ulcerative Colitis. - Azathioprine (Azasan, Imuran) - Mercaptopurine (Purixan)

How to dispose of patches?

in most cases press adhesive surfaces together some highly potent nicotine patches (Duragesic, Butrans) and Daytrana can be fatal if taken by someone else and it may be recommended to flush the patch down the toilet when done.

MS symptom control drugs - incontinence - constipation - diarrhea - muscle spasms/pain - tremor - depression

incontinence: anticholinergics constipation: laxatives diarrhea: loperamide muscle spasms/pain: baclofen (muscle relaxants) tremor: propranolol depression: SNRI that can also be used for neuropathic pain

Lab: Thyroid Stimulating Hormone (TSH)

increased (hypothyroidism): TKIs, lithium, carbamazepine decreased (hyperthyroidism) amiodarone and interferons can increase or decrease it

Lab: Amylase

increases: pancreatitis which can be caused by didanosine, stavudine, GLP-1 agonists, DPP-4i's, valproic acid, hypertriglyceridemia

Lab: Lipase

increases: pancreatitis which can be caused by didanosine, stavudine, GLP-1 agonists, DPP-4i's, valproic acid, hypertriglyceridemia

Aminosalicylates

indicated for the tx of UC - Mesalamine (Apriso) primary one - Sulfasalazine (Azulfidine) not use bc ADE - Balsalazide (Colazal) - Olsalazine (Dipentum)

Warfarin DDI

major substrate of 2C9 and minor of other CYPs - 2C9 inducers decrease INR: carbamazepine, rifampin - 2C9 inhibitors increase INR: amiodarone, fluconazole, metronidazole, bactrim When starting amiodarone decrease the dose of Warfarin by 30 - 50% Increase bleeding risks: NSAIDs, antiplatelets, other anticoagulants, SSRIs, SNRIs: these all increase the bleeding risk but not increase INR Drugs that increase clotting risks (estrogens and SERMs) should be DC if possible Increased bleeding risks with the "5 G's" - garlic, ginger, ginkgo, ginseng, glucosamine - high doses of fish oil - St. John's Wort decreases effectiveness of Warfarin Consume a consistent amount of vitamin K (additional vitamin K will decrease INR)

Liver Damage and Cholesterol medications

many cholesterol lowing medications cause liver damage: - niacin - fibrates - potential statins and ezetimibe These drugs should not be used if the AST or ALT are > 3 times the upper limit of normal

Lab: Reticulocyte count

measure the amount of reticulocytes (immature RBCs) being made by the bone marrow increases: blood loss decreases: untreated anemia, bone marrow suppression

Identifying the Cause of Anemia

microcytic anemia: iron studies (likely cause iron deficiency) MOST COMMON normocytic: acute blood loss, malignancy, CKD, bone marrow failure (aplastic anemia), hemolysis macrocytic anemia: likely causes vitamin B12 or folate deficiency

Factors affecting drug removal during diaylsis

molecular weight/size: small molecules are more readily removed by dialysis volume of distribution: drugs with large Vd are less likely to be removed by dialysis protein binding: drugs with high protein binding are less likely to be removed by dialysis dialysis factors - membrane: high-flux (large pore size) and high-efficiency (large surface area) HD filters remove more substances - blood flow rate: higher dialysis flow rates increase drug removal

Chemotherapy Drugs that are Vesicants

Anthracyclines - antidote: Dexrazoxane (Totect) or dimethyl sulfoxide Vinca Alkaloids - antidote: hyaluronidase

Acute Coronary Syndromes

Non-ST segment elevation acute coronary syndrome (NSTE-ACS) - Unstable angina - NSTEMI ST segment elevation myocardial infarction (STEMI)

IV drugs that come as colored solutions

Anthracyclines (doxorubicin): red, turns sweet and urine red Rifampin: red, turns body fluids and teeth red/orange Mitoxantrone: blue, turns skin, eyes and urine blue

Air Pressure for compounding

Non-hazardous: can be positive in SEC and PEC Hazardous: must be negative

Vaccine Information Statement (VIS)

prepared by the CDC for each vaccine, to explain the benefits and risks. Federal law requires that the VIS be handed to the patient (or parent before the vaccine is given.

Odds Ratio (OR)

probability that an event will occur, verse the probability that it will not occur ex OR=1.23, there is a 23% increased risk of falls with fractures

KD that are constipating

- antacids (Al and Ca containing) - clonidine - colesevelam - drugs with anticholinergic effects: - antihistamines, antispasmotics, phenothiazines, TCAs, urge incontinence drugs, iron, Non-DHP CCBs, Opioids, Sucralfate

DOC for Bacteroides fragillis

- Metronidazole - beta-lactam/beta-lactamase inhibitor - Cefotetan, cefoxitin - Carbapenems

Number needed to harm (NNH)

# of pts who need to be tx for a certain period of time in order for 1 pt to experience harm Same formula as NNT but its rounded down this time and absolute value is used A study reports 3.9% risk of bleed in tx group and 2.8% in control group ARR= 2.8 - 3.9 = -1.1% -> 1.1% there is a 1.1% higher risk of major bleeding in the tx group NNH= 1 / 0.011 = 90.9, rounded down to 90 one additional case of major bleeding is expected to occur for every 90 pts taking clopidogrel

Steps for treating severe hyperkalemia

*1. Stabilize the heart* - prevent arrhythmias - Calcium gluconate *2. Move it* - shift excess K intracellularly - regular insulin, dextrose, sodium bicarbonate, albuterol *3. Remove it* - enhance K elimination - furosemide, sodium polystyrene sulfonate, patiromer, sodium zirconium cyclosilicate, hemodialysis pts with diabetes are at higher risk for hyperkalemia as insulin deficiency reduces the ability to shift K into the cells

Treatment goals for Diabetes

- A1C: < 6.5 - 7% - Preprandial BG: 80 - 130 - 2-hr PPG: <180

Quinolones Overview

- MOA: inhibit bacterial DNA topoisomerase IV and DNA gyrase (topoisomerase II). - Concentration dependent antibacterial activity (high Cmax wanted) - Broad gram + - and atypical pathogens. - Ciprofloxacin and Levofloxacin have Pseudomonas coverage - Moxifloxacin has enhanced gram + coverage and cannot be used for UTI's - Delafloxacin has activity against MRSA - BBW: - tendon inflammation or rupture - peripheral neuropathy - CNS effect, seizures - avoid in pts with MG - Warning: QT prolongation - Avoid in children, pregnancy and breastfeeding - Photosensitivity

Osmotic Laxatives

- Magnesium hydroxide: Milk of magnesia - Polyethylene glycol 3350: Miralax - Glycerin: Fleet Liquid Glycerin Supp - Lactulose: Constulose, Enulose - Sodium Phosphates (Fleet Enema)

DOC Pseudomonas aeruginosa

- Piperacillin/tazobactam - Cefepime - Ceftazidime - Ceftazidime/Avibactam - Ceftazidime/Tazobactam - Carbapenems (not ertapenem) - Ciprofloxacin and levofloxacin - Aztreonam - Aminoglycosides - Colistimethate, polymyxin B

Garbing for Hazardous Drug Compounding

- Respirator: N95 that is fit tested - Gloves: two pairs of powder free gloves must be worn and changed every 30 minutes or when torn, punctured or contaminated. One pair goes under the cuff of the gown and one goes over. - Head and neck covers - Eye/Face protection: when there is a risk for HD spills - Chemotherapy gown: must be disposable and impermeable, change every 2 - 3 hrs or immediately after a spill or splash - Shoe covers: two pairs when compounding sterile HD.

DOC for community associated resistant Staphylococcus aureus (CA-MRSA) SSTI's

- SMX/TMP - Doxycycline, minocycline - Clindamycin - Linezolid

Motion sickness drugs

- Scopolamine (Transderm Scop) anticholinergic - Dimenhydrinate (Dramamine) Antihistamine - Meclizine (Dramamine all day less drowsy, bonine) antihistamine

Starting Oral Contraception

- Start today and requires backup for 7 days - Start Sunday after onset of menstruation if pt prefers menstruation during week Progestin Only: can start any day

Only anticholinergics approved for asthma

- Tiotropium (Spiriva Respimat) - Ipratropium (Atrovent)

What to use to prevent? - Wernicke's encephalopathy - Korsakoff syndrome

- Wernicke's encephalopathy: thiamine (vitamin B1) - Korsakoff syndrome: thiamine

Injection sites for insulin

- abdomen preferred - can also use posterior upper arm, superior buttocks and lateral thigh area

Consideration for Birth Control selection - acne - breastfeeding - estrogen CI - migraine - fluid retention/bloating - Menorrhagia - HTN - mood changes or disorders - nausea - overweight - postpartum - Premenstrual dysphoric disorder - spotting/breakthrough bleeding - wishes to avoid monthly cycle/menses

- acne: COC with low androgenic activity - breastfeeding: progestin only (POP) or nonhormonal - estrogen CI: POP or nonhormonal - migraine: - aura: POP or nonhormonal - no aura: any method - fluid retention/bloating: drospirenone containing - menorrhagia: COC (4 placebo days rather than 7) - HTN: POP or nonhormonal - Mood changes or disorder: monophasic COC - Nausea: take at night w/ food, decrease estrogen or POP - overweight: any method but counsel that patch may not be as effective - postpartum: no COC for 3 - 6 weeks, use POP or nonhormonal - Premenstrual dysphoric disorder: Yaz or antidepressant - spotting/breakthrough bleeding: wait 3 cycles before switching, may need to increase estrogen and if continued may need to increase progestin dose - wishes to avoid monthly cycle or menses: use extended or continuous formulas

Opioid BBW

- addiction, abuse and misuse can lead to overdose and death. - resp depression, which can be fatal. - use of opioids with BZDs, or other CNS depressants can increase the risk of death - do not consume alcohol with Kadian, Nucynta ER, oxymorphone ER and Zohydro - accidental ingestion/exposure of even one dose in children can be fatal. - crushing, dissolving or chewing of the long-acting products can cause the delivery of a potentially fatal dose. - life threatening neonatal opioid withdrawal with prolonged use during pregnancy.

NSAID DDI

- additive bleeding risk - caution with ototoxic agents (aminoglycosides, IV loop diuretics - can increase levels of lithium and methotrexate

BMP: Phosphate (PO4)

2.3 - 4.7 increases: renal failure decreases: phosphate binders, foscarnet, oral calcium intake

BMP: Bicarbonate

22 - 26 increases: loop diuretics, systemic steroids decreases: topiramate

Diabetes diagnosis

3 different tests - Hemoglobin A1C >/= 6.5% or FBG >/= 126 but these test must be confirmed by testing again with a new sample. - Oral Glucose Tolerance Test (OGTT) - does not need to be repeated

Vaccines for infants and children

3 dose hepatitis B started at birth other vaccine series start at age 2 months, including: Prevnar13, DTaP, Hib, polio, rotavirus Live vaccine series generally start at age >/= 12 mo, including: MMR, varicella No polysaccharide vaccines before age 2 annual flu vaccines recommended for everyone >/= 6 months

BMP: Potassium

3.5 - 5 increases: ACEi, ARBs, aldosterone receptor antagonists, alikiren, canagliflozin, cyclosporine, tacrolimus, K supplements, Bactrim, drospirenone containing oral contraceptives decreases: steroids, beta-2 agonists, diuretics, insulin

Malaria quick start

4 Strains - P. vivax most common - P. falciparum most deadly Prophylaxis: start prior to travel and continue after Malaria drugs cause N so take with food/water quick start started days before travel, good for short notice

BMP: Anion gap

5 - 12 calculated and presence of an anion gap suggests metabolic acidosis

Anemia in Oncology

Anemia can recover on its own, be treated with a RBC transfusion or rarely with ESAs (epoetin alfa: epogen, procrit, or darbepoetin alfa: aranesp) ESAs shorten survival and increase tumor progression so therefor ESAs are not recommended for patients with cure as their intent.

Normocytic anemia

Anemia of chronic kidney disease TX: iron therapy an erythropoiesis-stimulating agents (ESAs) IV iron 1st line for pts on hemodialysis and Non-HD can use oral iron

Drug Treatment for GERD and Peptic Ulcer disease

Antacids: - Calcium Carbonate: Tums - Calcium Carbonate + Magnesium: Mylanta Supreme - Calcium carbonate + Simethicone: Maalox Advanced Maximum strength) - Magnesium hydroxide: Milk of Magnesia - Sodium Bicarbonate/aspirin/citric acid: Alka-Seltzer Histamine-2 receptor Antagonist - Famotidine: Pepcid - Ranitidine: Zantac - Cimetidine PPI - Esomeprazole: Nexium - Lansoprazole: Prevacid - Omeprazole: Prilosec - Dexlansoprazole: Dexilant - Pantoprazole: Protonix

KD Select Drugs That Require Decrease or Increase Interval in CKD

Anti-Infectives - aminoglycosides - beta-lactams - fluconazole - quinolones - vancomycin CV drugs - LMWH (enoxaparin) - Rivaroxaban - Apixaban - Dabigatran GI drugs - H2RAs (famotidine, ranitidine) - Metoclopramide Others - bisphosphonates - Lithium

KD Medications/Illicit Drugs that can cause Psychotic Symptoms

Anticholinergics (central acting at high doses) Dextromethorphan Dopamine or dopamine agonists Interferons Stimulants Systemic steroids Illicit Substances: bath salts, cannabis, cocaine, lysergic acid diethylamide (LSD), methamphetamine, phencyclidine (PCP

Drugs with Additive/Adverse QT Prolongation Risks

Antiarrhythmics (amiodarone, dofetilide, dronedarone, ibutilide, sotalol) + Antibiotics/antifungals (quinolones and macrolides, azoles) + antidepressants (TCAs, SSRIs [highest risk with citalopram and escitalopram], SNRIs, mirtazapine, trazodone) + antipsychotics (most) + antiemetics (5-HT3 receptor antagonist, ondansetron) + others (donepezil, fingolimod, methadone) do not exceed citalopram 40 mg/day or 20 mg/day in >60yo. do not exceed escitalopram 20 mg/day or 10 mg/day in >60yo.

KD That Can Increase or Prolong The QT Interval

Antiarrhythmics (class 1, especially 1a and class III) Antibiotic: quinolones and macrolides Azole antifungals: all except isavuconazonium Antidepressants: Tricyclics, SSRIs (sertraline preferred in cardiac pts), SNRIs, Mirtazapine, and trazodone Antiemetic drugs: 5-HT3 receptor antagonists (droperidol and phenothiazines) Antipsychotics (most): chlorpromazine, clozapine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone, thioridazine, ziprasidone Other drugs: donepezil, fingolimod, methadone, tacrolimus

Drugs that can Worsen Myasthenia Gravis

Antibiotics: aminoglycosides and quinolones Magnesium salts select antiarrhythmics BB's and CCBs select antipsychotics muscle relaxants local anesthetics

Locating Guidelines for Common Conditions Anticoagulation CVD Diabetes Infectious Disease Oncology Pediatrics Pregnancy/Women's Health Psychiatric Conditions Pulmonary Conditions Renal Disease Vaccines

Anticoagulation: American College of Chest Physicians (CHEST): stroke prevention in Afib, VTE CVD: American College of Cardiology/American Heart Association (ACC/AHA): ACS, Afib, HF, high cholesterol, HTN Diabetes: American Association of Clinical Endocrinologists (AACE), American Diabetes Association (ADA) Infectious Disease: Infectious Diseases Society of America (IDSA), STDs CDC Oncology: American Society of Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN) Pediatrics: The American Academy of Pediatrics (AAP) Pregnancy/Women's Health: The American College of Obstetricians and Gynecologists (ACOG) Psychiatric Conditions: American Psychiatric Association (APA), Diagnostic and Statistical Manual of Mental disorders (DSM-5) Pulmonary Conditions Asthma: Global Initiative for Asthma (GINA) CODP: Global Initiative for Chronic Obstructive Lung Disease (GOLD) Renal Disease: Kidney Disease Improving Global Outcomes (KDIGO) Vaccines: Advisory Committee on Immunization Practices (ACIP), CDC

Selecting the Best Antidepressant - Cardiac/QT risk - Smoker - Peripheral neuropathy or pain - Taking Serotonergic Antidepressants - Seizure disorder - Pregnant - Daytime sedation - Insomnia - Sexual Dysfunction

Antidepressant needs to be taken for 4-8 weeks at therapeutic dose to see results and if it did not work do not use it again Cardiac/QT risk: sertraline (zoloft) preferred - do not use citalopram (celexa) or escitalopram (lexapro) Smoker: Bupropion SR approved for smoking cessation Peripheral pain or neuropathy: duloxetine Taking serotonergic antidepressants: avoid multiple serotonergic agents due to risk of serotonin syndrome. Increased risk of bleeding w/ certain drugs Seizure disorder or at risk: DONT use Bupropion Pregnant: DONT use Paroxetine. - mild-moderate depression: psychotherapy 1st line - severe depression: certain SSRI's 1st line Insomnia: - do not take activating drugs later in the day (bupropion, fluoxetine) - sedating: take at night (paroxetine, mirtazapine, trazodone) Sexual dysfunction: high risk with SSRIs and SNRIs - lower risk with bupropion and mirtazapine

Drugs with Additive Risks Serotonergic Toxicity

Antidepressants (SSRIs, SNRIs, TCAs, Mirtazapine, Trazodone) + MOA inhibitors (isocarboxazid, phenelzine, tranylcypromine), selegiline, rasagiline, linezolid, methylene blue + Buspirone + Dextromethorphan + Dihydroergotamine + Lithium + Lorcaserin + Opioids + Metoclopramide + Triptans + St. John's wort + Tegaserod

Neuroleptic Malignant Syndrome

Antipsychotics used to be called neuroleptics. NMS occurs commonly with FGAs due to D2 blockade Signs: hyperthermia, extreme muscle rigidity, mental status changes Labs: increased creatine phosphokinase and WBCs TX: taper off the antipsychotic quickly, provide supportive care

Black Widow Spider Bite Antidote

Antivenin for Latrodectus mactans Primary tx is Supportive care: opioids for pain, benzos for muscle spasms

Scorpion Stings Antidote

Antivenin immune FAB Centruroides (Anascorp)

Waste Bin Colors

Black: for bulk hazardous drug waste - any container (drug vials, IV bags) that contain a clear visible amount of an HD Yellow: Trace HD waste - empty syringes, IV bags, used PPE Red: infectious waste, non-hazardous sharps

Dosing Considerations for Select Highly Toxic Drugs - Bleomycin - Doxorubicin - Cisplatin - Vincristine

Bleomycin: lifetime max cumulative 400 units - pulmonary toxicity Doxorubicin: lifetime max cumulative 450-550 mg/m^2 - cardiotoxicity Cisplatin: dose per cycle not to exceed 100 mg/m^2 - nephrotoxicity Vincristine: single dose capped at 2 mg - neurotoxicity

Anticoagulation in Pregnancy

For Prevention and Treatment of VTE in pregnant women LMWH is preferred over UFH. Warfarin is teratogenic so convert to LMWH Oral factor Xa inhibitors and direct thrombin inhibitors are not recommended bc they have not been studied in pregnancy

Pneumococcal vaccines

Conjugate vaccine PCV13 (Prevnar 13) Polysaccharide vaccine PPSV23 (Pneumovax 23) Children <5 yo should receive Prevnar 13 PCV13 for: - immunocompromised - adults >/=65 (optional PPSV23 recommended for all adults >/=65 - multiple doses of PPSV23 spaced 5 years see pg 336

Traditional (non-biologic) disease modifying antirheumatic drugs (DMARDs)

For RA Methotrexate (Trexall) Hydroxychloroquine (Plaquenil) Sulfasalazine Leflunomide (Arava)

Steroids: Least Potent to Most Potent

Cortisone Hydrocortisone Prednisone Prednisolone Methylprednisolone Triamcinolone Dexamethasone Betamethasone

KD Select Drugs that are CI in CKD

CrCl < 60 - Nitrofurantoin (Macrodantin, Macrobid) CrCl < 50 - Tenofovir disoproxil containing products - Voriconazole (IV due to its vehicle) CrCl < 30 - Tenofovir alafenamide containing products - NSAIDs - Dabigatran - Rivaroxaban - Others: Avanafil, bisphosphonates, duloxetine, Fondaparinux, potassium sparing diuretics, tadalafil, tramadol ER GFR < 30 - SGLT2 inhibitors ("-flozin) - Metformin

Cockcroft-Gault equation

CrCl = ((140 - age) x IBW)/(72 x SCr) - Multiply by 0.85 if the patient is female - Use actual body weight if less than IBW, use IBW if normal weight, use adjusted body weight if overweight - Used to estimate kidney function

Chemo drugs that can be given Intrathecally

Cytarabine Methotrexate Hydrocortisone Thiotepa These all must be preservative free

Iron and Aluminum Antidote

Deferoxamine (Desferal)

Interleukin receptor antagonists (MaBs)

For asthma Mepolizumab (Nucala) Reslizumab (Cinqair) Benralizumab (Fasenra) Dupilumab (Dupixent)

Intravenous (Parenteral) Iron

Due to risks of more serious ADRs and cost IV iron therapy is reserved for: - CKD on hemodialysis - CKD receiving erythropoiesis-stimulating agents (ESAs) - Unable to tolerate oral iron - Losing iron to fast to replace Iron sucrose (Venofer), Ferumoxytol (Feraheme) For iron deficiency anemia BBW (Ferumoxytol): anaphylactic rxns ADE: hypersensitivity rxns, muscle aches, flushing hypotension Give by slow IV injection or infusion to reduce the risk of hypotension

Errors of Omission vs Errors of Commission

Errors of Omission - something was left out that is needed for safety - ex failing to warn a pt about an important ADE Errors of Commission - something was done incorrectly - ex prescribing bupropion to a pt w/ seizure hx

Benzodiazepine Antidotes

Flumazenil: can cause seizures when used in pts on bzds chronically

Toxic Alcohols: ethylene glycol (antifreeze), methanol overdose antidote

Fomepizole is preferred; ethanol (2nd line)

Hormonal Therapies for Prostate Cancer

Gonadotropin-releasing hormone (GnRH) antagonists (alone) or a GnRH agonists (initially given with an antiandrogen antagonists: degarelix (firmagon) agonists: leuprolide (lupron depot), goserelin (zoladex)

Comparison of Hepatitis Viruses

Hepatitis A - Acute - fecal-oral transmission - vaccine available - 1st line tx: supportive Hepatitis B - acute and chronic - blood and body fluid transmission - vaccine available - 1st line tx: PEG-INF (alpha) or NRTI (tenofovir or entecavir) Hepatitis C - acute and chronic - blood and body fluid transmission - NO vaccine - 1st line tx: Treatment naive: DAA combination - alternative: DAA Combo + RBV or DAA combo + RBV + PEG-INF

KD Select Drugs with Boxed Warning for Liver Damage

Hepatoxic drugs are typically DCed when the LFTs are > 3 times the upper limit of normal acetaminophen amiodarone isoniazid ketoconazole methotrexate nefazodone nevirapine NRTIs Propylthiouracil Tipranavir Valproic acid

Antiemetic Regimens for Acute/Delayed Nausea and Vomiting

High emetic risk (>90%) (ex cisplatin): 3 or 4 drug regimen - NK1-RA + 5HT3-RA + Olanzapine + Dexamethasone (PREFERRED REGIMEN) - Olanzapine + Palonosetron + Dexamethasone - NK1-RA + 5HT3-RA + Dexamethasone Moderate risk (30-90%): 2 or 3 drug regimen: - NK1-RA + 5HT3-RA + Dexamethasone - 5HT3-RA + Dexamethasone Low risk (10-30%) - 1 drug (any except NK1-RA)

Do not shake or Agitate Drugs

Hormones, proteins, albumin, alteplase, immune globulins, insulins, monoclonal antibodies, rasburicase, some vaccines

Solvents

Hydrophilic Solvents - water, water for sterile preparations, alcohols (can also be preservatives), glycols (PEG can serve as a surfactant, solvent or lubricant) Hydrophobic Solvents - Oils and fats (mineral oil)

Cyanide/Nitroprusside Antidote

Hydroxocobalamin (Cyanokit)

Common Toxicities of Tyrosine Kinase Inhibitors

Hypothyroidism Hepatic toxicity (hepatic metabolism Diarrhea QT prolongation Skin rash

Procainamide

IA antiarrhythmic (NOT USED OFTEN) BBW: agranulocytosis, long term use leads to positive antinuclear antibody (ANA), drug induced lupus

Quinidine

IA antiarrhythmic (NOT USED OFTEN) Hemolysis risk (avoid use in G6PD deficiency), can a positive Combs test ADE: drug induced lupus, D, stomach cramping, cinchonism (OD symtoms: tinnitus, hearing loss, blurred vision, HA, delirium)

Vaccines route of administration

IM ONLY: most vaccines are IM except some exceptions SC ONLY: MMR, MMRV, Varicella, Zostavax, Yellow fever, Dengue, Smallpox and Monkeypox IM or SC: PPSV23 Intranasal: FluMist Quadrivalent PO: Typhoid (Vicotif)

I-RUN-TO-THE-CAN

Irinotecan: causes cholinergic excess including diarrhea with ab cramping Atropine can be given to block the patients acute diarrhea Pilocarpine is the classic cholinergic drug and causes salivation, used for xerostomia (dry mouth) caused by some cancer drugs

Class Ib Antiarrhythmics

Lidocaine (Xylocaine); Mexiletine (NOT USED OFTEN) MOA: block Na channels Used for ventricular arrhythmias (no efficacy in AFIB)

Binders

Major excipient - adds cohesion to allow tablets to stick together and provide stability and strength - acacia, starch paste, sucrose syrup

Flavoring and coloring agents

Major excipient - aspartame, sucralose, glycerin, dextrose, lactrose, mannitol, sorbitol, ect

Diluents and Fillers

Major excipient - bulk up and dilute - lactulose, starches, bentonite, cellulose, petrolatum

Disintegrates

Major excipient - helps break up tab - alginic acid, polacrillin potassium, cellulose products, starch

Buffers

Major excipient - helps determine how much of the compound is ionized vs nonionized - potassium phosphate, sodium acetate/citrate, hydrochloric acid, boric acid, potassium

Lubricants

Major excipient - prevent ingredients from sticking to each other and to equipment - Magnesium stearate

Preservatives

Major excipient - slow or prevent microorganism growth - "benz" benzalkonium chloride, benzyl alcohol, chlorhexidine, povidone iodine

Container Incompatibility

Majority of drug containers are PVC and these use DEHP, which can leach into some solutions. - DEHP is toxic to the liver and testes - if drugs have issues with DEHP the containers should be polyolefin, polypropylene or glass containers - Insulin leaches

How to use MDI

Make sure everything is connected and shake for 5 seconds if first dose prime 4 times remove mouth piece breath out fully through mouth expelling as much air as possible. Holding the inhaler upright place the mouth piece into mouth and close lips around it. while breathing in slowly and deeply through your mouth press the top of the canister all the way down. after you have inhaled all the way take out mouth piece, close mouth and hold for up to 10 seconds. If another inhalation is needed wait 1 minute and repeat. Place cap back on when finished.

Drug Treatment for Systemic Lupus Erythematosus (SLE) - mild - moderate - severe

Malar rash (butterfly rash) on face common with SLE Try to avoid the use of chronic steroids Mild: may do well on NSAID Moderate to severe: may pts will need to be on one or more immunosuppressants or cytotoxic agents to control the disease: - hydroxychloroquine, cyclophosphamide, azathioprine, mycophenolate mofetil, and cyclosporine - May take up to six months to see max benefit from tx

Bipolar disorder Acute Treatment - manic episode - depressive episode

Manic episode: 1st line tx valproate (depakote), lithium or an antipsychotic. A combo of an antipsychotic + lithium or valproate is preferred for severe episodes Depressive episode: 1st line lithium, but lamotrigine can be used as an alternative

Freezer and Refrigerator Temp Monitoring

Monitored once daily in SEC and if they contain vaccines they need to be BID - fridge: 2 - 8C - Freezer: -50 to - 15C SEC (buffer room): 68F or 20C or cooler

Types of Mortars and Pestles

Mortar: bowl Pestle: blunt heavy stick A compounding pharmacy needs at least one glass and one Wedgewood or porcelain mortar and pestle Glass: used for liquids such as suspensions and solutions, and for mixing compounds that are oily or can stain Wedgewood: have a rough surface and are preferred for grinding dry crystals and hard powders Porcelain: have a smooth surface and are preferred for blending powders and pulverizing gummy consistencies.

Beta-Blockers in HTN

No longer recommended 1st line for uncomplicated HTN unless the patient has a comorbid condition for which a beta-blocker are recommended 1st line (post-MI, stable ischemic heart disease, HF) Beta-blocker for HF: bisoprolol, carvedilol, metoprolol succinate

Aluminum hydroxide

Phosphate binder RARELY used in CKD due to risk of Al accumulation (can cause nervous system and bone toxicity) Take with meals TID and skip if meal is skipped ADE: aluminum intoxication, "DIALYSIS DEMENTIA"

Risk vs Relative Risk (or Risk Ratio)

Relative risk (RR) is the ratio in the exposed group (treatment) divided by risk in the control group RR= (risk in treatment group) / (risk in control group) Risk= # (of subjects in a group with an unfavorable event) / (total number of subjects in group) EX. 10,111 pt were followed for 12 months. Metoprolol N=5123, HF progression=823. Control N=4988, HF progression=1397 Metoprolol risk= 823 / 5123 = 0.16 control risk= 1397 / 4988 = 0.28 RR= 0.16 / 0.28 = 57% RR = 1 (or 100%)implies no difference RR > 1 (or 100%) implies greater risk of the outcome in the tx group. RR < 1 implies lower risk (reduced risk) of the outcome in the tx group In this study metoprolol pts were 57% AS LIKELY to have progression of disease as placebo-tx pts. Relative risk reduction (RRR): 1 - 0.57 = 0.43. Metoprolol tx pts are 43% less likely to have HT

Rare and serious adverse effects of estrogen

Remember ACHES - A: abdominal pain that is severe - ruptured liver tumor or cyst or ectopic pregnancy - C: chest pain - MI or PE - H: headaches - Stroke - E: eye problems - blood clot in eye - S: swelling or sudden leg pain - DVT

Treatment approaches for stable ischemic heart disease (SIHD)

Remember: ABCDE A: Antiplatelet and antianginal drugs (aspirin; clopidogrel if allergy to aspirin) (beta blockers 1st line, can use CCBs if additional relief needed) (SL nitroglycerin for all patients with angina) B: blood pressure and beta blockers C: cholesterol (statins) and cigarettes (cessation) (SIHD is part of ASCVD) D: diet and diabetes E: exercise and education

KD Common Live Vaccines

Remember: COZY IV RM Cholera Oral typhoid Zoster (Zostavax) (for shingles) Yellow fever Intranasal influenza Varicella Rotavirus MMR others: tuberculosis (BCG), dengue, smallpox, ebola

KD Do Not Refrigerate

Remember: Dear Sweet Pharmacist, Freezing Makes Me Edgy: - Dexmedetomidine (Precedex) - Sulfamethoxazole/Trimethoprim (Bactrim) - Phenytoin (Dilantin) - crystalizes - Furosemide (lasix) - crystalizes - Metronidazole - Moxifloxacin (Avelox) - Enoxaparin (Lovenox)

Classifying Drugs With Vaughan Williams

Remember: Double Quarter Pounder, Lettuce, Mayo, Fries Please! Because Dieting During Stress Is Always Very Difficult Class I: Na-channel blocker, negative inotrope (weakens contraction) Ia: Disopyramide, Quinidine, Procainamide Ib: Lidocaine, Mexiletine Ic: Flecainide, Propafenone (BOTH CI with structural heart disease: MI and HF) Class II: primarily used to slow HR in ventricular tachycardias Beta-blockers Class III: K-channel blockers, primarily Dronedarone (+ alpha, beta, Ca and Na), Dofetilide, Sotalol (+ BB), Ibutilide, Amiodarone (+ alpha, beta, Ca and Na) Class IV: negative inotropic effect Verapamil, Diltiazem

KD That Cause or Worsen HF

Remember: Drug Information NATION D: dipeptidyl peptidase 4 inhibitors ("-gliptin") I: immunosuppressants, TNF inhibitors (adalimumab, etanercept) and interferons N: nondihydropyridine CCB's (diltiazem, verapamil) A: antiarrhythmics (class 1 agents: procainamide, quinidine, flecainide) T: thiazolidinedione's (increase risk of edema: pioglitazone, "-glitazone:) I: Itraconazole O: oncology drugs (anthracyclines: doxorubicin) N: NSAIDs others: systemic steroids, amphetamines, triptans, excessive alcohol

Common resistant pathogens

Remember: Kill Each And Every Strong Pathogen K: Klebsiella pneumoniae (ESBL, CRE) - ESBL: extended-spectrum beta-lactamases - CRE: carbapenem-resistant Enterobacteriaceae E: Escherichia coli - ESBL - CRE A: Acinetobacter baumannii E: Enterococcus faecalis, Enterococcus faecium (VRE) - VRE: vancomycin resistant Enterococcus S: Staphylococcus aureus (MRSA) - MRSA: Methicillin-resistant Staphylococcus aureus P: Pseudomonas aeruginosa

KD with leaching/absorption/absorption issues with polyvinyl chloride (PVC) containers

Remember: Leaches Absorbs To Take In Nutrients - L: Lorazepam - A: Amiodarone - T: Tacrolimus - T: Taxanes - I: Insulin - N: Nitroglycerin

Depression Diagnosis

Remember: M SIG E CAPS Need at least 5 of the following during the same two week period

NSAID Peptic Ulcer Treatment

Stop NSAID and PPI for 8 weeks Cytoprotective drugs - Misoprostol (Cytotec) - BBW: an abortifacient: do not use in women of childbearing age to decrease NSAID ulcers - ADE: diarrhea and ab pain - Sucralfate (Carafate) - ADE constipation

Management of HIT Complicated by Thrombosis (HITT)

Stop all forms of heparin and LMWH including flushes. If the pt is on warfarin then DC it and vitamin K should be administered. In pts with HIT argatroban is recommended.

Bridging Anticoagulation

Stop warfarin 5 days before major surgery Use LMWH or UFH

KD Hazardous drugs

all antineoplastics abortifacient - misoprostol antibiotics - chloramphenicol - telavancin anticoagulants - warfarin antifungals - fluconazole - voriconazole antiretrovirals (HIV) - Abacavir, entecavir, nevirapine, zidovudine antivirals, cytomegalovirus - cidofovir, ganciclovir, valganciclovir ance - isotretinoin arrhythmias - dronedarone autoimmune - acitretin, leflunomide, teriflunomide, fingolimod, interferon beta BPH - dutasteride, finasteride Depression - paroxetine dyslipidemia - lomtapide seizure/epilepsy - clobazam, clonazepam, carbamazepine, eslicarbazepine, divalproex, fosphenytoin, phenytoin, topiramate, vigabatrin, zonisamide gout - colchicine hepatitis - ribavirin hormones - androgen (testosterone), estrogens, progesterone's, SERMs, ulipristal hypercalcemia of malignancy - pamidronate, zoledronic acid insomnia - temazepam, triazolam migraine - dihydroergotamine hyperthyroidism - methimazole, propylthiouracil Pulmonary HTN - ambrisentan, bosetan, macitentan, riociguat renal disease - darbepoetin alfa schizophrenia - ziprasidone transplant - azathioprine, cyclosporine, mycophenolate, tacrolimus, sirolimus

Inflammation/Autoimmune Disease Labs

all non-specific C-Reactive Protein (CRP) Rheumatoid Factor (RF) Erythrocyte Sedimentation Rate (ESR) Antinuclear Antibodies (ANA)

Drugs with Additive/Adverse Nephrotoxicity Risks

aminoglycosides, amphotericin B, polymyxins, vancomycin cisplatin (amifostine to protect kidneys) CNIs: cyclosporine, tacrolimus Loop diuretics (especially IV) NSAIDs Radiographic-contrast dye

Drugs with Additive/Adverse Ototoxicity Risks

aminoglycosides, cisplatin, loop diuretics (especially rapid IV admin), salicylates (aspirin, salsalate, magnesium salicylate), vancomycin

KD Drugs Most Commonly Associated With Photosensitivity

amiodarone diuretics (thiazide and loop) methotrexate oral and topical retinoids quinolones st johns wort sulfa antibiotics tacrolimus tetracyclines voriconazole 1st gen antihistamines carbamazepine chloroquine coal tar fluorouracil griseofulvin NSAIDs quinidine tigecycline

Lab: Lactic acid (Lactate)

anaerobic metabolism, which occurs in long distance running and certain medical conditions (sepsis) Increases: NRTIs, metformin

Vaccines for healthcare professionals

annual flu vaccine usually required hep B if there is no evidence of vaccine series completion or blood test showing immunity Tdap: 1 dose if not up to date then Td or Tdap every 10 years Varicella: if there is no vax hx or chickenpox infection MMR: if there is no hx of vax or blood test showing immunity

Vaccinations for sickle cell disease and other causes of asplenia

annual flu vaccines recommended for everyone >/= 6 months H. influenzae type b (Hib) Pneumococcal vaccines (Prevnar 13 and Pneumonvax 23) - before age 65: 1 dose of Prevnar 13 (if not received previously) and 2 doses of Pneunovax23 - give Prevnar 13 1st then Pneunovax 23 >/=8 weeks later; give the 2nd pneunovax 23 >/= 5 years after the 1st dose Meningococcal vaccines

Vaccinations for adults

annual flu vaccines recommended for everyone >/= 6 months Tdap, Td: Tdap x 1 if not received previously Td or Tdap every 10 years Shingles: Shingrix preferred (2 dose series, 2nd dose 2-6 months after 1st); vaccinate all adults >/= 50 even if they previously had chicken pox or zostavax HPV: adults </= 26 who did not complete the series Pneumococcal Pneumovax 23: all adults >/=65 - Pts 2-64 1 dose if heart, lung, liver disease, diabetes, alcoholic abuse, smokers - Pts 2-64 2 doses if immunocompromised Prevnar 13 (if not received before) - any pts >/=6 who are immunocompromised - optional for adults >/=65 Meningococcal - 1 or 2 vaccines Hep B - sexually active adults not in long-term single relationship, pts with diabetes age 19-59, healthcare providers, IV drug abusers, HIV or chronic liver disease Hep A - adults traveling to underdeveloped countries

Vaccinations for immunodeficiency

annual flu vaccines recommended for everyone >/= 6 months Live vaccines are CI Pneumococcal vaccines (Prevnar 13 and Pneumonvax 23) - before age 65: 1 dose of Prevnar 13 (if not received previously) and 2 doses of Pneunovax23 - give Prevnar 13 1st then Pneunovax 23 >/=8 weeks later; give the 2nd pneunovax 23 >/= 5 years after the 1st dose HIV (CD4) count < 200 cells/mm^3) - Meningococcal conjugate vaccines (Menactra or Menveo) - Hep A vaccine - Hep B vaccine

Vaccinations for pregnancy

annual flu vaccines recommended for everyone >/= 6 months (inactivated for any trimester) live vaccines are CI Tdap x 1 with each pregnancy

Lab: Rapid Plasma Reagin (RPR)

antibody test to screen for syphilis

Lag and suicide Prevention with Antidepressants

antidepressants must be used daily and will take time to work. Physical symptoms can improve in 1-2 weeks Psychological symptoms such as low mood may take a month or longer

Agents for chemotherapy induced diarrhea (CID)

antimotility agents: - loperamide (usual maximum dose is 16 mg/day but for CID can do 24 mg/day) - diphenoxylate + atropine Fluorouracil, capecitabine and irinotecan commonly cause CID that can occur several days after chemo

Medication Error

any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Includes error is prescribing, order communication, product labeling and packaging, compounding, dispensing, administration, education and monitoring.

Asthma in pregnancy

asthma control can worsen during pregnancy so continue ICS (budesonide is typically used)

amidine

basic functional group

amine (primary)

basic functional group

amine (tertiary)

basic functional group

imine

basic functional group

Lab: Antifactor Xa Activity

obtain peak anti-Xa 4 hrs after SC LMWH used to monitor LMWHs and unfractionated heparins LMWH recommended for pregnancy increases: heparins, LMWHs, fondaparinux

Medications that lower testosterone

opioids (especially methadone) chemotherapy drugs cimetidine (tagamet) (H2 antagonist) spironolactone

hydroxyl group

or alcohol neutral functional group

Antibiotic special requirement

page 380

basic metabolic panel

per book "pharmacist should know which values are contained in the stick diagrams" these values are generally provided on the NAPLEX

Gram stains for select bacterial organisms

pg 352